2019 TENTH EDITION
Unlocking a decade of medical pharmacy growth.
TABLE OF CONTENTS
02
07
31
03
11
32
Introduction
Medical Pharmacy Trends
Executive Summary
Medical Pharmacy Therapy Categories
2019 Report Methodology and Demographics
Appendix member medical drug claim volume
05
19
06
29
Medical Pharmacy Overview
Medical Pharmacy Management
Medical Pharmacy Trend Drivers
Yuqian Liu, Pharm.D. Director, Specialty Clinical Solutions
Michael Polson, Pharm.D. Vice President, Clinical Outcomes Analytics
Laura Walters, R. Ph. Director, Specialty Clinical Solutions
Troy Phelps Senior Director, Analytics
Amy Ware, Pharm.D. Director, Specialty Clinical Solutions
Rebecca Borgert, Pharm.D., BCOP Senior Director, Clinical Strategy, Oncology
Kameron Kelly, Pharm.D. Manager, Specialty Clinical Solutions
Steve Cutts, Pharm.D. Senior Vice President and General Manager, Specialty
Aaron Aten, Pharm.D., BCPS Director, Specialty Clinical Solutions
Sneha Sharma, Pharm.D. Pharmacist Liaison
Kristen Reimers, R.Ph. Senior Vice President, Specialty Clinical Solutions
Michelle Booth, Pharm.D. Director, Specialty Clinical Solutions
Misty Greficz Director, Marketing CONTRIBUTORS Mostafa Kamal CEO, Magellan Rx Management
Glossary
Industry Update and Pipeline
Keiran Enright Senior Director, Underwriting
EDITORIAL STAFF Stephanie Stevens, MPH Director, Marketing, Research and Publications
54
PAYER ADVISORY BOARD Martin Burruano, R.Ph. Vice President, Pharmacy Services, Independent Health Andrew Colby, R.Ph., MBA Sr. Director of Clinical Pharmacy, Health New England Patrick Gill, R.Ph. Director of Pharmacy Programs, Horizon BCBS of New Jersey Scott McClelland, Pharm.D. Vice President of Pharmacy, Florida Blue Carly Rodriguez, Pharm.D. Pharmacy Director, Clinical Innovation, Moda Health
© 2020 Magellan Rx Management. Magellan Rx Management 2019 Medical Pharmacy Trend Report™ is published in conjunction with D Custom. All rights reserved. All trademarks are the property of their respective owners. Printed in the U.S.A. The content — including text, graphics, images, and information obtained from third parties, licensors, and other material (“content”) — is for informational purposes only. The information contained herein represents the opinions of Magellan Rx and no other third party or customer. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Figures may be reprinted with the following citation: Magellan Rx Management Medical Pharmacy Trend Report™, © 2020. Used with permission.
1
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
INTRODUCTION Magellan Rx Management is pleased to present the 10th edition of its Medical Pharmacy Trend Report™, the only detailed source analyzing medical benefit drug claims for trends and data benchmarking, as well as current medical benefit drug management approaches. Over the past 10 editions of this report, we have seen a remarkable evolution of medical pharmacy. In 2010, plans were just starting to manage drugs on the medical benefit; there were only nine approvals for medical injectable drugs, and biosimilars were talked about but still five years away. Now the medical benefit is top of mind, and in 2019 alone, there were triple that number of approvals, seven of them biosimilars. Medical pharmacy continues to grow, with advancements in research and technology creating surges in the approvals of novel and more-costly treatments. Consequently, the management of provider-administered therapeutic drugs is an ever-moving target that requires increasingly innovative strategies. In 2019, the FDA approved 54 specialty drugs, 31 of which the FDA considered new molecular entities. Medical pharmacy drugs accounted for 31 of the total 54 specialty approvals, or 57%, representing continued strong growth of specialty drugs covered under the medical benefit. In addition to new drug approvals, numerous current drugs received new indications, increasing their market share and spend. The trend in new drug approvals is not slowing. By 2024, the number of billion-dollar drugs is expected to increase 15%, from 33 drugs in 2018 to 38 in 2024 (see figure 59). In our 2019 survey, we asked payers their greatest concern regarding the medical benefit: 61% were concerned with medical benefit spend, 44% with oncology spend specifically, and 46% with the increasing number of gene therapies (n=54). Interestingly, when we asked this same question 10 years ago, only 32% of payers were concerned with medical drug costs and a mere 15% were concerned with oncology spend (n=60) — another example of rapid growth and the changing mindset within the
industry. As biosimilars start to penetrate the market in a meaningful way, we may begin to see some cost savings. However, newer, costly therapies — including gene therapies — are being introduced and will continue to divert attention. In addition to the rise of gene therapy, the past 12 to 18 months witnessed the continued proliferation of oncology immunotherapies, including Keytruda and Opdivo, both of which are now in the top 10 drugs by spend for commercial and the top five for Medicare and Medicaid. Keytruda managed to eclipse Opdivo in Medicare and Medicaid; they landed at the No. 2 and No. 3 spots, respectively. This year, we are addressing these big headlines, as well as payers’ concerns, via deep dives into biosimilar reimbursement and management, what’s happening in the hot categories of hemophilia management and CAR-T therapy, oncology immunotherapy spend, and how forecasting is shaping medical benefit management decisions. We are also continuing our in-depth profiles of the major medical pharmacy therapy categories, a five-year look at per-member-per-month (PMPM) spend, and current and innovative medical pharmacy management strategies. As we celebrate 10 editions of the Medical Pharmacy Trend Report, we know you will glean valuable insights on the always changing medical benefit drug trend. Magellan Rx has been providing medical drug trend reporting for more than 10 years and, with more than 15 years of medical pharmacy management expertise, continues to lead the industry in innovative medical pharmacy specialty solutions.
2010 Report
2019 Report
COMMERCIAL PMPM
$17.28
90%
$32.83
MEDICARE PMPM
$45.59
35%
$61.47
TOP COMMERCIAL CATEGORY: ONCOLOGY
$7.43
54%
$11.42
TOP COMMERCIAL DRUG: REMICADE
$0.94
214%
$2.95
2010
9 medical pharmacy drug approvals The most expensive drug in the world is Soliris, at $410,000.
2015
In March, Zarxio becomes the first biosimilar approved in the U.S.
2017
In August, Kymriah becomes the first gene therapy approved in the U.S.
10 YEARS
of reporting the trends you need to know magellanrx.com/trendreport
2019
31 medical pharmacy drug approvals The most expensive drug in the world is now Zolgensma, at $2.1M; Soliris now costs $500,000.
2019 / MAGELLANRX.COM/TRENDREPORT
2
EXECUTIVE SUMMARY COMMERCIAL
MEDICARE
PMPM TREND
PMPM TREND
$57.11
$19.94
$25.49
$21.68
$29.77
2015
2016
ANNUAL COST PER PATIENT
2017
2018
2014
2018 MEDICAL DRUG SPEND SPECIALTY
NONSPECIALTY
$45,097 2018
43% of spend ($14.15)
31% 96%
of patients
of spend
69%
of patients
4%
of spend
2018 TOP DRUG TRENDS
Top 10 Drugs
2017
2018
2018 MEDICAL DRUG SPEND SPECIALTY
Keytruda
Opdivo
79%
50%
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
$10,590 2017
$10,463 2018
2018 CATEGORY TRENDS
Rank YOY: No. 14 to No. 9 Rank YOY: No. 8 to No. 6 PMPM YOY: $0.47 to $0.84 PMPM YOY : $0.70 to $1.05
3
2016
5-year trend
NONSPECIALTY
-1%
2018 CATEGORY TRENDS
Oncology and oncology support accounted for:
2015
ANNUAL COST PER PATIENT
+2%
2017
+40%
+8%
5-year trend
Top 10 Drugs
$44,264
$46.56
$45.86
+65%
+10% 2014
$43.90
$32.83
$61.47
Oncology and oncology support accounted for:
55% of spend ($33.95)
47% 98%
of patients
of spend
53%
of patients
2%
of spend
2018 TOP DRUG TRENDS
Keytruda
Yervoy
93%
53%
Rank YOY: No. 9 to No. 2 Rank YOY: No. 29 to No. 24 PMPM YOY: $2.12 to $4.09 PMPM YOY: $0.40 to $0.61
MANAGEMENT TRENDS†
MEDICAID PMPM TREND
Vial Rounding (n=9)
Dose Optimization/ Drug Wastage (n=14)
$8.46
$7.58
$6.13
2014
$10.93
$10.26
+7%
2015
2016
ANNUAL COST PER PATIENT Top 10 Drugs
2017
5-year trend
SAVINGS ACHIEVED
2018 MEDICAL DRUG SPEND
Targeted Management Strategies
NONSPECIALTY
-16%
2017
$7,497 2018
2018 CATEGORY TRENDS
Oncology and oncology support accounted for:
43% of spend ($4.68)
SAVINGS ACHIEVED
2018
SPECIALTY
$8,924
10%
9%
+78%
40% 96%
of patients
of spend
60%
of patients
4%
of spend
2018 TOP DRUG TRENDS
Keytruda
Elaprase
75%
45%
Rank YOY: No. 10 to No. 3 Rank YOY: No. 22 to No. 18 PMPM YOY: $0.24 to $0.42 PMPM YOY: $0.11 to $0.16
Weight-Based Dosing (n=2)
8%
SAVINGS ACHIEVED
Site of Service (n=14)
23% SAVINGS ACHIEVED
†Savings self-reported. 2019 / MAGELLANRX.COM/TRENDREPORT
4
MEDICAL PHARMACY OVERVIEW Medical pharmacy is a low-volume, high-cost business. In 2018, across all lines of business, less than 12% of members had a medical drug claim; Medicare saw more than twice the number of claims that commercial or Medicaid saw; and commercial medical pharmacy trend was at its lowest in three years, at 10%. The decrease comes from a slowdown in utilization compared to previous years. Payers are also using more sophisticated medical pharmacy management strategies. Medicare trend lowered from 23% in 2017 to 8% in 2018. Medicaid followed suit with a 7% trend in 2018, down from 21% in 2017. Commercial and Medicaid spend were focused in the hospital outpatient (OP) setting, at more than 50% of the spend, while Medicare spend was concentrated in the physician office, at close to 60% of the spend. This is largely due to differences in reimbursement methodologies in the hospital outpatient setting. In Medicare, reimbursement is based on ASP, whereas in commercial and Medicaid, it is largely based on percentage of billed charges (see figure 1). Higher growth in home infusion may have been due to more plans implementing site of service programs for high-cost medical pharmacy drugs. FIGURE 1: MEDICAL PHARMACY ALLOWED AMOUNT PMPM 2017-2018
COMMERCIAL
MEDICARE
MEDICAID
members with medical drug claim
members with medical drug claim
members with medical drug claim
5.4%
11.9%
$35.20
$32.69 $9.90
$9.12
+8%
+9% $16.17
$14.83
$21.01
$20.32
+9% $5.82
+3% $6.77
+16% 2017
2018
% CHANGE
Home Infusion
Hospital OP
2017 Total PMPM
$29.77
$4.10
Physician
2018 Total PMPM
$32.83
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
$5.27
+29% 2017
+10% TREND
5
4.9%
Home Infusion
Hospital OP
2017 Total PMPM
$57.11
2018
% CHANGE
+0.5%
$5.52
+9%
$1.03
+12% 2017
Physician
2018 Total PMPM
$61.47
+8% TREND
$3.72
Home Infusion
$6.04 $1.15 2018
% CHANGE
Hospital OP
2017 Total PMPM
$10.26
$3.74
Physician
2018 Total PMPM
$10.93
+7% TREND
MEDICAL PHARMACY TREND DRIVERS Commercial, Medicare, and Medicaid trends were primarily driven by unit costs (allowed per unit) resulting from a 5% or greater increase in inflation or increased costs of drugs on the medical benefit (see figures 2, 3, and 4). ASP index or reimbursement rates remained largely unchanged from the previous year. Unit volume, although not the main contributor, had an influence on trend too, based on increased prevalence (number of claims) year over year. The number of units used or prescribed per patient slightly decreased in commercial but was relatively flat in Medicare and Medicaid. Interestingly, unit volume had a double-digit influence in the previous report, representing a shift of cost versus utilization driving the trend for 2018. Across commercial, Medicare, and Medicaid, there were more than 50 categories of medical benefit drugs. Of those, the top 10 categories made up the majority of spend, accounting for more than 70% of PMPM spend across all lines of business (see figures 5, 6, and 7). In Medicare, members per 1,000 was significantly higher due to an overall higher number of utilizers, especially in categories such as oncology, ophthalmic injections, and asthma/COPD — each of which had at least eight members per 1,000. Not surprisingly, the single category with the highest growth across all lines of business — although it was not in the top 10 for commercial or Medicare — was CNS agents for rare diseases, which contains drugs such as Exondys and Spinraza. For the 2018 data, more than 280 medical benefit drugs were included in our analysis. Of those drugs, the top 25 drugs alone accounted for close to — if not more than — two-thirds of medical pharmacy spend (see figures 8, 9, and 10). That percent of total spend jumps to 75% in commercial, 84% in Medicare, and 78% in Medicaid for the top 50 drugs. Cost per patient for the top 25 is almost double in Medicaid, due to higher utilization of more costly rare-disease drugs such as Exondys, Elaprase, and Spinraza.
COMMERCIAL
MEDICARE
MEDICAID
FIGURE 2: 2018 TREND CONTRIBUTORS
FIGURE 3: 2018 TREND CONTRIBUTORS
FIGURE 4: 2018 TREND CONTRIBUTORS
6.2%
Unit Volume
4.6% Total
Prevalence
Unit per Patient
Allowed per Unit
5.7%
6.5%
-0.9%
Overall PMPM Trend
Total
-1.6%
Inflation
ASP Index
10.3%
$25.43
77%
PMPM
% of PMPM
PMPM
3.1
Members/1K
61%
% of PMPM
-0.2%
Total
Prevalence
Unit per Patient
4.7%
5.3%
-0.6%
Total
Inflation
ASP Index
7.6%
5.5
Members/1K
$51.13
83%
PMPM
% of PMPM
$65,198
$42.11 PMPM
20.5
Members/1K
Allowed per Unit
69%
% of PMPM
0%
Total
Prevalence
Unit per Patient
3.9%
4.5%
-0.7%
Total
Inflation
ASP Index
6.5%
FIGURE 7: 2018 TOP 10 DISEASE STATES OR DRUG CATEGORIES
44.9
Members/1K
FIGURE 9: 2018 TOP 25 PHARMACY DRUGS
Cost per Patient
2.7%
2.7%
Unit Volume
Overall PMPM Trend
FIGURE 6: 2018 TOP 10 DISEASE STATES OR DRUG CATEGORIES
FIGURE 8: 2018 TOP 25 PHARMACY DRUGS
$20.12
Allowed per Unit Overall PMPM Trend
FIGURE 5: 2018 TOP 10 DISEASE STATES OR DRUG CATEGORIES
3.2%
3%
Unit Volume
$8.09
74%
PMPM
% of PMPM
7.6
Members/1K
FIGURE 10: 2018 TOP 25 PHARMACY DRUGS
$36,836
Cost per Patient
$6.71 PMPM
4.3
Members/1K
61%
% of PMPM
$113,264
Cost per Patient
2019 / MAGELLANRX.COM/TRENDREPORT
6
MEDICAL PHARMACY TRENDS FIGURE 12: TOP 10 COMMERCIAL DISEASE STATES OR DRUG CATEGORIES BY PMPM SPEND 2018
COMMERCIAL
PMPM
Commercial oncology and oncology support accounted for 43%, or $14.15, of allowed amount PMPM. In total, Biologic Drugs for Autoimmune Disorders (BDAIDs) were the second-highest-spend category, accounting for 16% of PMPM, or $5.33.
% change 2017-2018
% of 2018 total PMPM
14% $11.42
The category with the highest growth was CNS: rare diseases, with Exondys and Spinraza, which also led to the highest annual cost per claim at $38,000 (see figure 63). For the 10th year in a row, the top five commercial drugs were Remicade, Neulasta, Rituxan, Herceptin, and Avastin. Remicade saw decreases in PMPM due to the introduction of biosimilars Renflexis and Inflectra. We may see similar trends in upcoming data since all of these top 5 agents now have marketed biosimilars. Ocrevus made a strong impact after a full year on the market at No. 8 and contributed to MS’s category growth of 73% — the overall second-highest category growth.
8% $3.28
15% $2.66
2% $2.10
73% $1.54
Oncology
BDAID: Crohn’s Disease/ Ulcerative Colitis
Immune Globulin
ColonyStimulating Factors
Multiple Sclerosis
35%
10%
8%
6%
5%
-25% $1.20
-3% $1.18
Antihemophilic BDAID: Factor Rheumatoid Arthritis
4%
4%
1% $0.74
16% $0.71
15% $0.60
EnzymeReplacement Therapy
Hematology
Asthma/COPD
2%
2%
2%
Opdivo and Keytruda both continued strong with 50% and 79% increases in spend, respectively. FIGURE 13: 2018 TOP 10 COMMERCIAL MEDICAL BENEFIT DRUGS BY SPEND*
HIGHEST-COST DRUGS The 10 most expensive commercial medical benefit drugs (see figure 69)
$521,515
Average Per Patient Per Year
PMPM
$13.47
$1.00
Top 10 PMPM
Total PMPM
FIGURE 11: COMMERCIAL UNCLASSIFIED CODE AND SAMPLE DRUGS BY ALLOWED AMOUNT PMPM
-3% $2.95
Unclassified codes were in the top 20 for commercial.
J3490
Bridion, Cinvanti, Gattex, Radicava
$0.22
J3590
Brineura, Fasenra, Hemlibra
$0.09
J9999
Imfinzi, Poteligeo, Sylatron, Vyxeos
$0.07
C9399
Aliqopa, Bridion
$0.02
7
% change 2017-2018
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
Remicade
2% $2.00
Neulasta
7% $1.49
8% $1.40
Herceptin
Rituxan
*Due to rounding, totals may not add up exactly.
41%
% of total PMPM
1.6
ASP Index (avg.)
2% $1.17
50% $1.05
33% $0.92
N/A $0.85
Avastin
Opdivo
Entyvio
Ocrevus
1.2
AWP Index (avg.)
79% $0.84
Keytruda
13% $0.82
Gamunex-C/ Gammaked
FIGURE 15: TOP 10 MEDICARE DISEASE STATES OR DRUG CATEGORIES BY PMPM SPEND 2018
MEDICARE
PMPM
Medicare has experienced record PMPM growth over the last few years, likely related to increased patient volume, as well as an influx of novel, high-cost oncology treatments. Medicare oncology and oncology support accounted for 55%, or $33.95, of allowed amount PMPM — a 6% increase year over year.
% change 2017-2018
% of 2018 total PMPM
9% $28.10
Ophthalmic injections continue to be the second-highest-spend category, accounting for 13% of PMPM, or $7.89.
13%
» Eylea took over the No. 1 spot by PMPM spend with a 14%
$7.89
increase, overtaking Neulasta and Rituxan, while Lucentis came in as the sixth-highest-spend drug.
» Avastin remains the most cost-effective option in the category.
-6% $3.56
-8% $2.26
51% $1.48
Oncology
Ophthalmic Injections
Immune Globulin
ColonyStimulating Factors
BDAID: Rheumatoid Arthritis
Multiple Sclerosis
46%
13%
6%
6%
4%
2%
BDAIDs are still a factor in Medicare spend, with the category accounting for 6% of total PMPM spend, or $3.93. Opdivo maintained its spot at No. 3 on the medical benefit, while Keytruda (No. 2) surpassed Opdivo, almost doubling spend to $4.09 PMPM — a 93% increase from the previous year. Increased utilization due to FDA approval of additional indications drove this trend.
7% $3.62
0.4% $1.10
-2% $1.10
5% $1.03
0.2% $0.97
Erythropoiesis- Hematology BDAID: Crohn’s ViscoStimulating Disease/ supplementation Agents Ulcerative Colitis 2%
2%
2%
2%
FIGURE 16: 2018 TOP 10 MEDICARE MEDICAL BENEFIT DRUGS BY SPEND* PMPM
HIGHEST-COST DRUGS
% change 2017-2018
$29.85
The 10 most expensive Medicare medical benefit drugs (see figure 70)
$300,856
Average Per Patient Per Year
Top 10 PMPM
$1.67
49%
% of total PMPM
1.0
ASP Index (avg.)
0.8
AWP Index (avg.)
Total PMPM
FIGURE 14: MEDICARE UNCLASSIFIED CODE AND SAMPLE DRUGS BY ALLOWED AMOUNT PMPM
14% $4.47
93% $4.09
18% $3.72
-5% $3.34
-13% $3.19
12% $2.91
Unclassified codes were in the top 20 for Medicare.
J3490
Cinvanti, Durolane, Radicava, Sufentanil
$0.28
J9999
Besponsa, Imfinzi
$0.21
J3590
Fasenra
$0.05
C9399
Aliqopa, Bridion
$0.01
Eylea
Keytruda
Opdivo
Neulasta
Rituxan
Lucentis
14% $2.45
-5% $2.19
Xgeva/ Prolia
Avastin
0.1% $1.91
-21% $1.56
Herceptin
Remicade
*Due to rounding, totals may not add up exactly.
2019 / MAGELLANRX.COM/TRENDREPORT
8
MEDICAL PHARMACY TRENDS FIGURE 18: TOP 10 MEDICAID DISEASE STATES OR DRUG CATEGORIES BY PMPM SPEND 2018
MEDICAID
PMPM
Medicaid saw a 7% increase in PMPM spend, with oncology being the highest-cost category. In Medicaid, oncology and oncology support accounted for 43%, or $4.68, of allowed amount PMPM.
HIGHEST-COST DRUGS The 10 most expensive Medicaid medical benefit drugs (see figure 71)
$330,606
Average Per Patient Per Year
% of 2018 total PMPM
3% $3.66
Top drugs are comparable to commercial, with Remicade, Neulasta, and Avastin in the top five. However, as with Medicare, Opdivo broke into the top five in last year’s report and maintained its spot in 2018. Keytruda (No. 3) again had the largest growth in spend, with a 75% increase in spend year over year. With Medicaid having a younger population, the highest-cost drugs in terms of allowed amount per patient were for a variety of rare diseases, as evidenced by Spinraza and Exondys making the top 10 for this line of business.
% change 2017-2018
-11% $0.80
Oncology
34%
-1% $0.66
24% $0.61
N/A $0.55
-18% $0.49
ColonyContraceptives CNS Agents: BDAID: Stimulating Crohn’s Disease/ Rare Diseases Factors Ulcerative Colitis
7%
6%
6%
46% $0.38
33% $0.36
15% $0.31
-3% $0.28
Immune Globulin
Multiple Sclerosis
Enzyme Replacement Therapy
Botulinum Toxins
BDAID: Rheumatoid Arthritis
4%
3%
3%
3%
3%
5%
$1.29 PMPM
FIGURE 19: 2018 TOP 10 MEDICAID MEDICAL BENEFIT DRUGS BY SPEND* PMPM
% change 2017-2018
$4.19
Top 10 PMPM
FIGURE 17: MEDICAID UNCLASSIFIED CODE AND SAMPLE DRUGS BY ALLOWED AMOUNT PMPM
-7% $0.77
Besponsa , Imfinzi
$0.04
J3490
Cinvanti, Durolane, Radicava
$0.02
J3590
Fasenra
$0.01
75% $0.42
9
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
Remicade
1.5
ASP Index (avg.)
0.9
AWP Index (avg.)
-11% $0.77
Unclassified codes were in the top 25 for Medicaid.
J9999
38%
% of total PMPM
Neulasta
Keytruda
*Due to rounding, totals may not add up exactly.
15% $0.39
13% $0.39
Avastin
Opdivo
-31% $0.39
Herceptin
N/A $0.28
Spinraza
13% $0.28
Botox
N/A $0.27
Exondys
12% $0.24
Implanon
Administrative Code Reimbursement The administration costs of medical benefit drugs were also a factor in the overall spend of these drugs. Site of administration continued to make an impact on total drug costs. Not surprisingly, the cost of administering chemotherapy in the hospital outpatient setting was double and sometimes triple that of administration in a physician’s office (see figure 20). Commercial administrative code spend reflected the administration of chemotherapy agents as the highest cost. Medicare administrative code spend paralleled top drugs, with the highest-spend categories involving chemotherapy administration and ophthalmic injections. Medicaid administrative code spend included chemotherapy treatment but was mainly general intravenous administration. FIGURE 20: 2018 TOP FIVE ADMINISTRATIVE CODES BY TOTAL PMPM FOR HOSPITAL OUTPATIENT AND PHYSICIAN OFFICE
COMMERCIAL CPT Code & Description 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug 95165 Supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)
Physician
$0.23
$0.34
MEDICARE Hospital
$0.61
$0.01
MEDICAID
Total PMPM
CPT Code & Description
Physician
Hospital
Total PMPM
$0.84
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
$0.49
$1.12
$1.61
$0.35
67028 Intravitreal injection of a pharmacologic agent (separate procedure)
$0.60
$0.70
Physician
Hospital
Total PMPM
96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
$0.13
$0.06
$0.19
$0.76
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
$0.03
$0.11
$0.14
$0.08
$0.68
96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
$0.00
$0.13
$0.13
$0.06
CPT Code & Description
96365 Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
$0.07
$0.25
$0.32
20610 General introduction or removal procedures on the musculoskeletal system
20610 Under general introduction or removal procedures on the musculoskeletal system
$0.29
$0.03
$0.32
96365 Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
$0.15
$0.48
$0.63
96361 Intravenous infusion, hydration
$0.00
$0.09
$0.09
$0.31
96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
$0.02
$0.60
$0.62
96365 Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
$0.01
$0.07
$0.08
96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
$0.23
$0.08
2019 / MAGELLANRX.COM/TRENDREPORT
10
MEDICAL PHARMACY THERAPY CATEGORIES Antihemophilic Factors Antihemophilic factor drugs have generally been a lower-volume category, averaging 0.01 members per 1,000. However, the average cost per claim is one of the highest, averaging close to $14,000 or more, and the average annual cost per patient is greater than $80,000 across all lines of business. Antihemophilic factor drugs were most frequently administered at home in both commercial and Medicare — 79% and 64%, respectively. In Medicaid, treatment was most frequently administered in the hospital outpatient setting; however, costs here can be much higher than when administered in the home. The pipeline is strong for this category due to the emergence of gene therapy, where several agents under development are anticipated to be curative and reduce overall medical cost of care for this category by reducing hospitalizations and individual bleed events. 2018 CATEGORY PMPM
2018 AVERAGE COST PER CLAIM
FORECAST Pipeline
$1.20
% change
Commercial
$26,375
Medicare
Medicaid
$2.62 $2.38
$0.51 $0.26
Commercial
Medicare
Medicaid
$15,880
Commercial
$13,945
Medicare
$1.97
$2.08
$2.12
$2.21
33%
Medicaid
2018 % OF MEDICAL DRUG SPEND COMMERCIAL COST PER CLAIM: FACTOR VIII
4%
1%
2%
Commercial
Medicare
Medicaid
11
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
17,437
$
HOME INFUSION
33,486
$
HOSPITAL OP
2018
2019
2020
2021
2022
2023
Asthma/COPD Asthma/COPD was a high-volume category with double-digit increases in trend across all lines of business. Xolair has the highest market share in commercial and Medicaid, while Pulmicort has the highest market share in Medicare (see Appendix figures 75, 76, and 77). Newer agents such as Cinqair and Nucala, although still outside of the top 25 drugs by spend, continue to gain market share, with Nucala having the second-highest market share in the category. Fasenra is another new agent gaining market share. Although volume of members was highest in Medicare, commercial costs per claim were higher, reflecting a larger population in Medicare utilizing lower-cost drugs.
2018 CATEGORY PMPM
2018 MEMBERS PER 1,000
FORECAST Pipeline
% change
Commercial
$0.97
2.4
8.0
3.5
Commercial
Medicare
Medicaid
Medicare
Medicaid
$2.43 $2.28 $2.15 $2.03
$0.60
$1.91
2018 AVERAGE COST PER CLAIM
36%
$1.79
$528 $0.22
Commercial
Medicare
Medicaid
$220
2017-2018 CATEGORY PMPM TREND
$153
15%
11%
29%
Commercial
Medicare
Medicaid
2018 Commercial
Medicare
2019
2020
2021
2022
2023
Medicaid
2019 / MAGELLANRX.COM/TRENDREPORT
12
MEDICAL PHARMACY THERAPY CATEGORIES Biologic Drugs for Autoimmune Disorders (BDAIDs) BDAIDs include the categories of Ankylosing Spondylitis (AS), Crohn’s Disease/Ulcerative Colitis (Crohn’s/UC), Psoriasis/Psoriatic Arthritis, Rare Autoinflammatory Conditions (RAC), Rheumatoid Arthritis (RA), and Systemic Lupus Erythematosus (SLE). BDAID spend continues to be highest in Crohn’s disease for commercial and Medicaid, while RA is the category leader in Medicare. Remicade is the leading drug across all three lines of business. Although not a market share leader (see Appendix figures 78, 79, and 80), Stelara saw claims lean toward the 45-unit dose across all lines of business, comprising 56% of commercial, 43% of Medicaid, and 67% of Medicare claims. Trend remained relatively flat in this category as Remicade market share decreased, with biosimilars Renflexis and Inflectra beginning to gain market share.
2018 CATEGORY PMPM
BDAIDS SPEND BY CATEGORY AS
Crohn’s/UC
Other
FORECAST
Psoriasis
RAC
RA
SLE
$5.33
Pipeline
% change
Commercial
Medicare
Medicaid
$0.15
$13.59 $1.18
$3.93
$0.03 $0.18
$14.09
$12.67 $11.87
$0.11
$0.43
$11.16
35%
$10.44 $2.26
$3.28 $0.31
$1.18
$1.03 $0.12
$0.10
Commercial
Medicare
6%
Commercial
Medicaid
Medicare
$0.03 $0.28 $0.66
$0.02 $0.10 $0.08 $0.02
Medicaid
BRAND WITH HIGHEST MARKET SHARE
2018 % OF MEDICAL DRUG SPEND
16%
$0.09
REMICADE
11%
56%
48%
62% 2018
Commercial
13
Medicare
Medicaid
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
Commercial
Medicare
Medicaid
2019
2020
2021
2022
2023
Immune Globulin (IG) Immune Globulin remained the third highest-spend category in commercial and Medicare and the sixth in Medicaid. Shifts in sites of service (SOS) were seen in this category as commercial and Medicare drug administration shifted from home and hospital outpatient sites of care, respectively, into the physician office. New products to market, such as Panzyga, are spreading the competition and will affect market share in the coming year. Opportunities may exist for SOS programs in Medicaid, where administration is mostly in the hospital outpatient setting. Movement into the home infusion SOS may reduce drug spend across all lines of business.
2018 CATEGORY PMPM
2018 % OF MEDICAL DRUG SPEND
FORECAST Pipeline
% change
Commercial
8%
$3.62
6%
Medicare
Medicaid
$8.94
4%
$8.50 $8.08
$2.66
Commercial
Medicare
$7.69
Medicaid
$7.18
32%
$6.77 COMMERCIAL COST PER CLAIM: GAMUNEX-C/GAMMAKED
$0.49 Commercial
Medicare
Medicaid
$6,415 $4,311
$4,090
2017-2018 CATEGORY PMPM TREND
15%
7%
-18%
Commercial
Medicare
Medicaid Physician
Hospital OP
Home Infusion
2018
2019
2020
2021
2022
2019 / MAGELLANRX.COM/TRENDREPORT
2023
14
MEDICAL PHARMACY THERAPY CATEGORIES Oncology Oncology remained the highest-cost category across all lines of business (LOB). Oncology spend makes up at least one-third of total medical drug spending across all LOBs and is approaching 50% of total spend in Medicare. Keytruda and Opdivo have experienced rapidly increasing utilization and spend, with Keytruda almost doubling in PMPM in Medicare. Medicare also has more than four times as many members when compared with commercial. As previously mentioned, oncology spend is a concern for payers, and oncology immunotherapies and gene therapy will continue to contribute to this spend. Many opportunities for savings are anticipated with the biosimilars for Avastin, Herceptin, and Rituxan. The gene therapy and biosimilar pipeline is robust in oncology, with upward of 700 drugs currently in clinical trials. In Medicare alone, the 2023 pipeline is projected to be worth $10.72 PMPM. 2018 CATEGORY PMPM
2018 % OF MEDICAL DRUG SPEND
COMMERCIAL MARKET SHARE AND PMPM: ONCOLOGY IMMUNOTHERAPIES
Oncology had the highest spend 10 years in a row.
$28.10
35%
46%
34%
Commercial
Medicare
Medicaid
Bavencio
Imfinzi
Tecentriq
Yervoy
Keytruda
Opdivo
6% 3%
$0.37 $0.09
2018 MEMBERS PER 1,000
$11.42 $3.66 Commercial
Medicare
1.8
8.7
0.8
Commercial
Medicare
Medicaid
53%
$1.04
Medicaid
2018 COMMERCIAL AVERAGE COST PER PATIENT 2017-2018 CATEGORY PMPM TREND
14%
9%
3%
Commercial
Medicare
Medicaid
OPDIVO
KEYTRUDA
$79,441
$76,134
27%
4%
$62,717
$73,197
2018
2017
15
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
33% $0.84
2018
2017
4%
1%
Market Share
$0.08
$0.01
Allowed Amount PMPM
Oncology Management Strategies Based on forecasting, growth in oncology is projected to soar 69% due to slight increases in utilization of current therapies — potentially with expanded indications — and, more dramatically, due to new pipeline approvals. The high cost of oncology therapy has urged healthcare stakeholders to explore cost-containment strategies while maintaining quality. Payers were open to cost-saving management strategies when appropriate. When efficacy and safety are equal but there is a cost disparity for oncology treatment regimens, 69% of payers would support removing criteria other than diagnosis/indication for the lower-cost option. In addition, 76% of payers were willing to restrict specified regimens based on the patient’s performance status (see figure 21).
FORECAST Pipeline
FIGURE 21: PAYERS’ PREFERRED ONCOLOGY MANAGEMENT STRATEGIES % of payers (n=54)
% change
Commercial
Medicare
Medicaid
$73.09
$62.71 $57.41 $50.06
$52.92
69%
$43.18
2018
2019
2020
2021
2022
76%
69%
Restricting specified regimens based on the patient’s performance status when aligned with National Comprehensive Cancer Network (NCCN) recommendations
Incentivizing lower-cost regimens when they carry the same level of compendia recommendation
54%
35%
Limiting agents that are recently approved by the FDA under an accelerated approval pathway to patients who meet the study eligibility criteria used for FDA approval
Not covering NCCN 2A recommendations if evidence is lacking
2023
2019 / MAGELLANRX.COM/TRENDREPORT
16
MEDICAL PHARMACY THERAPY CATEGORIES Oncology Support Oncology support includes antiemetics for chemotherapy-induced nausea and vomiting, colony-stimulating factors (CSFs), erythropoiesis-stimulating agents (ESAs) for anemia due to chemotherapy, and gastrointestinal: chemoprotectant/hormonal. The oncology support category remained approximately 10% of total medical drug spend. The majority of spend was from CSFs. CSFs saw a marginal increase in spend in the past year, yet still comprised 74%, 58%, and 76% of the category spend for commercial, Medicare, and Medicaid, respectively. As a combined category, oncology support represented the third-highest spend in commercial and Medicare and the second-highest spend in Medicaid. There are currently several biosimilars on the market in this category for the long- and short-acting CSFs and the ESAs. The predicted negative forecast growth illustrates their impact. Specifically, Neulasta biosimilars are now on the market, with Fulphila and Udenyca gaining market share. 2018 CATEGORY PMPM
2018 AVERAGE COST PER CLAIM
FORECAST Pipeline
$1,333
$5.85
% change
Commercial
$1,062 $805
$10.18
Medicare
$9.90
$2.74
$8.99
$1.02 Commercial
Medicare
Medicaid
Commercial
2017-2018 CATEGORY PMPM TREND
-3%
-14%
Commercial
Medicare
Medicaid
$9.20
$9.24
2018 % OF MEDICAL DRUG SPEND
CSFs
ESAs
$9.33
Medicaid
ONCOLOGY SUPPORT SPEND BY CATEGORY Antiemetics
3%
Medicare
Medicaid
-8%
Chemoprotectant GI
$0.87 $0.96
$0.21
$0.08 $3.41
$2.03
8% Commercial
17
10% Medicare
$0.03
9% Medicaid
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
$0.04
$0.78 $0.37
$0.59
Commercial
Medicare
$0.15
Medicaid
2018
2019
2020
2021
2022
2023
Ophthalmic Injections Ophthalmic injections had the greatest impact in Medicare as the second-highest-spend category and with Eylea being the highest-cost agent. In Medicare, eight members per 1,000 had an ophthalmic injection claim, compared to less than 0.5 per 1,000 in both commercial and Medicaid. With 2019’s approval of Beovu, there may be a shift in this category over the next few years. However, Avastin remained the most cost effective therapy in this category, at more than 20 times less costly.
2018 CATEGORY PMPM
2018 % OF MEDICAL DRUG SPEND
FORECAST Pipeline
% change
Commercial
$7.89
2%
13%
1%
Commercial
Medicare
Medicaid
2018 MEMBERS PER 1,000
Medicare
Medicaid
$11.82 $11.02 $9.69
$9.98 $10.15
$8.57
38% $0.54 $0.14 Commercial
Medicare
Medicaid
0.5
8.1
0.5
Commercial
Medicare
Medicaid
COMMERCIAL EYLEA VS. AVASTIN
2017-2018 CATEGORY PMPM TREND
10% Commercial
2018 MARKET SHARE
13% 100% Medicare
Medicaid
2018 COST PER PATIENT
EYLEA
40%
3%
$11,204
AVASTIN
34%
1%
20x less costly
$558
2018
2019
2020
2021
2022
2019 / MAGELLANRX.COM/TRENDREPORT
2023
18
MEDICAL PHARMACY MANAGEMENT
Top Management Trends Medical pharmacy management requires an ever-evolving balance of serving increasing populations and managing novel agents introduced to the market. We asked payers about their top concerns when thinking about drugs on the medical benefit. Most payers were concerned with the foundational issue of medical pharmacy spend, while the emergence of gene therapies was the next highest concern (see figure 22). Innovative management strategies such as site of service, weight-based dosing, vial rounding, and dose optimization are vital to help bend the trend. Payers are experiencing real savings from these programs. Plans were also utilizing unique medical benefit strategies such as using Institute for Clinical and Economic Review (ICER) guidelines to structure management programs and taking advantage of 340B pricing (see figure 23). In addition, payers have created targeted management programs such as: » Biosimilar and site of service mandates
» Performing clinical pharmacist review for some high-cost infusible drugs prior to initiation of therapy
» Bringing members back to plan-owned clinics when appropriate
» Eliminating provider buy and bill
» Rebates in medical pharmacy
FIGURE 23: MEDICAL PHARMACY STRATEGIES
FIGURE 22: TOP CONCERNS ABOUT MEDICAL PHARMACY % of payers (n=54)
Yes
Medical pharmacy spend
Don’t know
Rare diseases
61% Gene therapy
39% 13%
Medical pharmacy trend
46% Oncology
31%
Payment reform
New drugs to market
21%
31%
44%
22%
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
Follow ICER Guidelines (n=54)
56%
25%
Special Arrangements With In-Network 340B Systems (n=52)
54%
Rebate reduction
41%
19
No
11%
Utilization Management
Management: Unclassified Medical Pharmacy
Payers preferenced medical benefit drugs where multiple agents were available. Payers needed, on average, at least a 21% discount on a drug in order to preference that drug (see figure 24). Even so, payers are still managing medical pharmacy through utilization management tools, mainly prior authorization (PA), at 98%, and post-service claim edits (PSCE), at 50% (see figure 25). Payers reported average denial rates of 18% and overturn rates of 23% (see figure 26). Payers with post-service claim edits had denial rates of 9% and appeal rates of 10% but a low overturn rate of 4% (see figure 27).
New specialty drugs are managed similarly to existing specialty drugs, with PA and PSCE being implemented within three months of approval for three-quarters of the plans (see figures 28 and 29).
FIGURE 24: VALUABLE DISCOUNT
FIGURE 28: PA FOR NEWLY RELEASED MEDICAL BENEFIT DRUGS % of payers (n=48)
21%
% of payers (n=42) Yes, after FDA approval
4%
Yes, after product/NDC is available from the manufacturer
29%
Valuable Discount to Prefer Medical Benefit Drug
FIGURE 29: PSCE FOR NEWLY RELEASED MEDICAL BENEFIT DRUGS
46%
Yes, review performed prior to coverage decision (providers notified) No, we do not require a review on unclassified drugs
21%
26%
26%
24%
24%
FIGURE 25: UTILIZATION MANAGEMENT TOOLS Within 1 month after
% of payers (n=54)
36%
PA/step therapy
Other [SOS, rebates, vial rounding]
98% Post-service claim edits (PSCE)
26%
FDA Approval (n=22)
Differential provider reimbursement by class
50% Clinical pathways
13%
1-3 months after
36%
4-6 months after
10% 9% 9%
7-12 months after
40%
Within 1 month after
Other [ASAP; within days]
40%
40%
FDA Approval (n=10)
20%
None currently
39
2%
%
FIGURE 26: PA DETERMINATION RATES
FIGURE 27: PSCE DETERMINATION RATES
Weighted Rates (n=53)
Weighted Rates (n=27)
Product/NDC Availability (n=10)
40%
1-3 months after
30% 20% 10%
4-6 months after Other [ASAP; within days]
40%
Product/NDC Availability (n=10)
20%
23.2% 17.6%
19.1%
29%
8.9%
10.3% 4.0%
Denials
Appeals
Overturns
Denials
Appeals
Overturns
Product Release (n=14)
35% 29%
7
%
Within 1 month after
18%
1-3 months after
27%
4-6 months after 7-12 months after Other [varies]
27%
Product Release (n=11)
10% 18%
2019 / MAGELLANRX.COM/TRENDREPORT
20
MEDICAL PHARMACY MANAGEMENT
ONCOLOGY IMMUNOTHERAPY MANAGEMENT
Utilization Management: Category Specific We inquired about management strategies for hemophilia, oncology immunotherapies, and CAR-T cell therapies, since those were impactful categories in 2018 and 2019. We found that 67% of payers had a hemophilia strategy, of which 89% implemented a PA, 67% managed through some kind of support services such as case management, and 47% had some form of inventory management such as dosing limits (see figure 30). For oncology immunotherapies, 85% of payers used PA, while 35% used PSCE and 33% used a clinical pathway. Even so, 76% were not preferencing agents with shared indications representing potential opportunity. Since gene therapy was a concern for payers, 76% implemented a PA and 30% implemented outcomes-based payments, but more surprisingly, 19% did not know their gene therapy strategy (see figure 31). Rare disease management was mainly implemented through PA (93%) and case management (69%) (see figure 32).
% of payers (n=54)
85%
67%
35%
76%
of payers are not preferencing agents with shared indications
FIGURE 31: GENE THERAPY MANAGEMENT STRATEGY
72%
% of payers (n=54)
of payers without a hemophilia strategy are concerned about future spend (n=18)
Prior authorization (PA)
Performance-based annuity
76%
FIGURE 30: HEMOPHILIA MANAGEMENT STRATEGY
Outcomes-based payments
9% Risk pooling
30
6%
%
% of payers (n=36) Prior authorization (PA)
Exclude coverage of gene therapies
Weight-based dose optimization
89% Managed support services/case management
31%
Inventory management (i.e., dosing limits)
Don’t know
11% Milestone-based contract
Carved out to the pharmacy benefit
67%
19% Other [review at launch, ASO exclude]
9
4%
%
28% Short-acting therapy before long-acting therapy
47
19%
%
FIGURE 32: RARE DISEASE MANAGEMENT STRATEGY % of payers (n=54)
Assay management (i.e., matching the dose dispensed to the dose prescribed)
Pharmacokinetic testing requirements
44% Site of service/preferred network strategy
11% Immune tolerance induction therapy
44% Product preferencing
8%
33
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
PA/step therapy
Post-service claim edits
93
6
%
37%
%
Care/case management
Clinical pathways
69% Expert clinical review
Other [340B pass-through, prefer short acting] %
21
of payers used a clinical pathway to manage checkpoint inhibitors
of payers used PSCE to manage checkpoint inhibitors
HEMOPHILIA of payers had a hemophilia strategy (n=54)
33%
of payers used PA to manage checkpoint inhibitors
26% Differential provider reimbursement
52
%
7%
CAR-T THERAPY More and more providers utilized CAR-T therapies, and more payers tracked outcomes related to CAR-T therapies, both as a component of value-based agreements in place with some manufacturers and as a way of independently assessing the outcomes they are seeing in their populations receiving treatment with CAR-T therapies. Although typically requiring an inpatient stay, 78% of payers had a management strategy for both inpatient and outpatient therapy, while 46% did not require approval for that inpatient hospital stay (see figures 33 and 34). For CAR-T response rates, 40% of payers had less than a 50% response rate when it comes to CAR-T therapy (see figure 35). Even with these strategies and outcomes data, 21% of payers were not aware of their organization’s CAR-T reimbursement (see figure 36). FIGURE 33: CAR-T THERAPY MANAGEMENT: PA REVIEW
FIGURE 35: CAR-T OUTCOME RESPONSE RATES
(n=54)
(n=15)
47%
3% 6% 13%
Yes, for inpatient
27%
Yes, for outpatient Yes, for both inpatient and outpatient Don’t know
78%
13%
13% 0-24%
25-50%
51-75%
Don’t know
FIGURE 36: 2019 CAR-T REIMBURSEMENT FIGURE 34: CAR-T THERAPY MANAGEMENT: REVIEW STRATEGY Yes
No
26%
Don’t know
28%
Separate Review for Inpatient Stay (n=54)
46%
22%
11%
Bundle payment (drug products + associated care) via medical benefit without cap
11%
Bundle payment (drug products + associated care) via medical benefit with cap
13%
Drug product reimbursed via pharmacy benefit, associated care (i.e., inpatient, ICU, etc.) reimbursed via medical benefit
44%
Drug product and associated care (i.e., inpatient, ICU, etc.) reimbursed separately by individual CPT code via medical benefit
21%
Don’t know
28% Tracking Outcomes (n=54)
50%
% of payers (n=54)
2019 / MAGELLANRX.COM/TRENDREPORT
22
MEDICAL PHARMACY MANAGEMENT Utilization Management Programs Unique strategies are key components of a medical drug management program, and these programs are growing in popularity. In 2019, 59% of payers had dose optimization, 46% had vial rounding, and only 31% had weight-based dosing in place for oncology immunotherapies (see figures 37, 38, and 39). FIGURE 37: 2019 DOSE OPTIMIZATION PROGRAM Yes, it’s mandatory
Yes, it’s voluntary
FIGURE 38: 2019 VIAL ROUNDING
No
Yes, it’s mandatory
FIGURE 39: 2019 WEIGHT-BASED DOSING
Yes, it’s voluntary
No
Yes, it’s mandatory
Yes, it’s voluntary
No
11% 24%
28% Dose
(n=54)
20%
Weight-Based Dosing (n=54)
Rounding 54% Vial(n=54)
41% Optimization
22%
69%
31%
84%
53%
Immune Globulin (n=32)
Antihemophilic Factor (n=32)
Yes
No
47% BDAIDs (n=32)
Don’t know
Dose Optimization Savings (n=32)
72%
64%
Immune Globulin (n=25)
Yes
44% 3%
9%
Average Savings (n=14)†
†Savings self-reported.
23
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
No
Oncology (n=25)
+/-5%
32%
+/-10%
Vial Rounding Savings (n=25)
52%
10%
82%
Average Savings (n=9)†
76%
Keytruda (n=17)
Don’t know
12%
Opdivo (n=17)
Yes
Vial Rounding Limits (n=25)
52% 53%
52%
BDAIDs (n=25)
No
Other (n=17)
Don’t know
Savings from Weight-Based Dosing (n=17)
16%
don’t know
29%
6%
48%
8%
Average Savings (n=2)†
65%
2019 Site of Service (SOS) Program FIGURE 40: 2019 SOS PROGRAM Yes, it’s mandatory
Yes, it’s voluntary
No
SOS PROGRAM POPULATION
MEMBERS SHIFTED INTO SOS PROGRAM
(n=36)
(n=36)
94% 67%
58%
33%
34%
Into home infusion
39% SOS Program (n=54) Pediatric (ages 0-17)
28%
Adult (ages 18-64)
Senior (65+)
ADMINISTRATION OF SOS PROGRAM
29%
Into ambulatory infusion suite
(n=36) Categories Included (n=36)
72%
69%
Oncology Immunotherapies
67%
BDAIDs
Oncology Support
Oncology or Supportive Drugs (n=15)
80% ESAs
73% CSFs
73% Bisphosphonates/ Denosumab
64%
33%
CLINICAL POLICY CRITERIA
MEMBER BENEFIT DESIGN
19%
17%
FAVORABLE REIMBURSEMENT FOR LOWER-COST SITES OF SERVICE
MEMBER INCENTIVES (E.G., LESSER COPAY, COINSURANCE, GIFT CARDS)
11%
8%
NONE OF THE ABOVE
OTHER [GROUP CONTRACT, PA PROCESS]
24%
Into independent physician office
23%
Average Savings (n=14)†
†Savings self-reported. 2019 / MAGELLANRX.COM/TRENDREPORT
24
MEDICAL PHARMACY MANAGEMENT Biosimilar Strategies As of publication of this report (early March 2020), there were 26 FDA-approved biosimilar products across three different therapeutic categories, of which 15 have been launched. Thirteen of those were oncology/oncology support agents. The biosimilars currently on the market proved to have an impact on medical pharmacy strategy, as 40% of payers, based on number of lives, reported they were currently reimbursing based on a maximum allowable cost (equivalent reimbursement for reference and biosimilar) (see figure 42). Only 23% of payers, based on lives, reimbursed based on the Medicare model, an 11-percentage-point decline from last year. At the time of our survey (summer 2019), there were no oncology biosimilar products on the market but payers were planning to utilize the same formulary strategies for the oncology biosimilars, including step therapy. More than half of payers (63%) implemented a biosimilar step therapy program (see figure 44), most often for Remicade and Neupogen (see figure 46). Not surprisingly, 91% of payers stated significant cost differential as the No. 1 criterion for implementing a step for reference products, with an average savings of 29% to warrant the step therapy (see figures 41 and 45). FIGURE 41: 2019 BIOSIMILAR MANAGEMENT
FIGURE 42: BIOSIMILAR REIMBURSEMENT STRATEGY
(n=54)
% of lives (n=190 million)
40%
78%
23%
78% OF PAYERS REIMBURSED BIOSIMILARS THE SAME WAY THEY REIMBURSED ALL MEDICAL BENEFIT DRUGS.
13%
70%
Maximum Allowable Cost
70% OF PAYERS SAID PRICING OF BIOSIMILARS WAS MOST IMPACTFUL ON REIMBURSEMENT STRATEGY (RANKED AS THE NO. 1 CRITERION NEEDED TO IMPLEMENT A STEP).
Medicare Model
(WAC+6% then ASP+6% of reference product’s ASP)
Other
[Contract dependent, unknown, WAC-%]
10% AWP Minus x%
8% Comparable Drug Profit to Reference Product
6% Other ASP Plus x%
FIGURE 43: 2019 SAME FORMULARY BIOSIMILAR STRATEGY FOR ONCOLOGY
63%
% of payers (n=54)
63% OF PAYERS PREFERENCE THE BIOSIMILAR OVER THE REFERENCE PRODUCT.
67%
65%
65% 30%
29% ON AVERAGE, PAYERS NEEDED 29% SAVINGS TO WARRANT PREFERENCING A BIOSIMILAR.
Yes
for Herceptin 1
Yes
for Avastin
Yes
for Rituxan
Not Sure/ Don’t Know
Mulcahy, Andrew W. et al. “Biosimilar Cost Savings in the United States: Initial Experience and Future Potential.” Rand Health Quarterly, 2018, https://www.rand.org/pubs/periodicals/health-quarterly/issues/v7/n4/03.html.
25
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
$54 billion estimated savings in the U.S. due to biosimilars, from 2017 to 2026.1
FIGURE 44: 2019 BIOSIMILAR STEP THERAPY PROTOCOL
FIGURE 46: 2019 REFERENCE PRODUCTS OVER WHICH BIOSIMILARS ARE PREFERRED
% of payers Yes, for new starts only
Yes, for new starts and current utilizers
No
Don’t know
% of payers (n=34)
4% 25% 33%
Currently Implement (n=54)
37%
26%
Plan to Implement (n=20)
30%
40%
68%
68%
5%
53%
FIGURE 45: 2019 BIOSIMILAR STEP-THERAPY CRITERIA
44%
% of payers (n=54) Significant cost differential with biosimilar agent [average 29%]
91% Comparable side effect profile and risk of immunogenicity
78% Provider network acceptance/support of strategy
78%
6%
FDA designation of interchangeability
74% Member acceptance support of biosimilar product
48%
Neupogen
Remicade
Epogen/Procrit
Neulasta
Other [no step; they are tiered]
2019 / MAGELLANRX.COM/TRENDREPORT
26
MEDICAL PHARMACY MANAGEMENT Medical Benefit Drug Cost Share‡ In medical pharmacy, payer cost burden was at 96% or greater across all lines of business. In terms of members, Medicare had the highest cost share, at 4.2% (see figure 47). Commercial and Medicare cost shares were collected through coinsurance; surprisingly, 25% of commercial and 19% of Medicare required no cost share (see figure 48).
A minority of payers varied cost share by drug or indication — 13% and 2%, respectively. Although still a small percentage, almost one-third (29%) were varying cost share by site of service (SOS). Forty percent of plans varying cost share by SOS saw outcomes including cost savings and member satisfaction (see figures 49, 50, and 51). FIGURE 49: VARYING COST SHARE BY DRUG % of payers
6%
FIGURE 47: MEDICAL BENEFIT DRUG COST SHARE
2.5%
MEMBER
4.2%
MEMBER
Yes (positive outcomes)
13%
14%
(n=52) (n=32)
0%
95.8% PAYER
(n=42) 38%
86% Experiencing Outcomes
Capability to Vary by Drug
FIGURE 50: VARYING COST SHARE BY SOS
100% PAYER
% of payers
Yes (positive outcomes)
6% (n=52)
Medicare
(n=34)
Currently Vary by SOS
Don’t know
41%
38%
33%
65%
FIGURE 48: MEDICAL BENEFIT DRUG MEMBER COST SHARE TYPE
40% (n=15)
Medicaid
No
21%
27%
29% Commercial
43%
MEMBER
Currently Vary by Drug
PAYER
Don’t know
19%
(n=7)
81%
97.5%
No
Experiencing Outcomes
Capability to Vary by SOS
% of payers
FIGURE 51: VARYING COST SHARE BY INDICATION
COMMERCIAL (n=52)
25%
Copay
50%
Co-insurance
25%
Require neither
% of payers
6% 25%
MEDICARE (n=32)
28%
Copay
53%
Co-insurance
19%
Require neither
(n=52) (n=32)
92% Currently Vary by Indication
‡ Includes deductible, copay, and coinsurance.
27
Yes
2%
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
19% (n=48)
56% Capability to Vary by Indication
No
Don’t know
Health Information Data
60%
70%
of payers are currently collecting NDC data (n=52)
of payers use forecasting data across both medical and pharmacy benefit drugs (n=43)
25%
of payers have their providers collect and share quality and outcomes data (n=52)
FIGURE 52: 2019 ABILITY TO USE NDC DATA
FIGURE 54: USE OF FORECASTING DATA
FIGURE 56: PROVIDERS COLLECTING AND REPORTING OUTCOMES DATA
(n=31)
(n=54)
(n=52)
Capture of data
Yes, for actuaries and pricing
100%
Yes (ACO, HEDIS, MTM, NCQA)
69%
No
Yes, for program evaluation/adoption
Storage of data
46%
68%
25%
35
%
Don’t know
Yes, to determine future UM tools
39%
Report of utilization data by NDC
68
%
Not currently
40%
20% FIGURE 53: 2019 NDC DATA COLLECTION USE (n=31) In utilization management reviews
FIGURE 55: FREQUENCY OF FORECASTING DATA USAGE
FIGURE 57: MANAGEMENT CHANGES BASED ON QUALITY AND OUTCOMES DATA COLLECTION
(n=42)
(n=13) Annually
71%
4
%
In NDC-based pricing for brands vs. generics
48%
10
%
Vial management strategies
Monthly
48%
16%
Outreach programs
54%
Quarterly
Biennially (every other year)
Adjusted reimbursement based on quality metrics improvements
46% Have not implemented changes to date
31%
38
%
Other
13%
Changes to criteria
15%
2019 / MAGELLANRX.COM/TRENDREPORT
28
INDUSTRY UPDATE AND PIPELINE Congress Moves Forward on Drug Pricing but Finds It Difficult to Reach Agreement Both houses of the U.S. Congress were extremely active in drug-pricing policy issues throughout 2019, and the Trump administration and Congress are expected to continue aggressively pursuing policy changes in this area throughout 2021 and beyond. In the spring of 2019, the House passed legislation designed to prevent delay tactics and to improve competition by increasing market access for generics. That legislation still awaits Senate action.2 In the summer of 2019, all major Senate committees advanced major drug pricing legislation. The various bills included:
» establishing an inflation rebate for Medicare Part D drugs
» incentivizing increased use of biosimilars
» limiting consumer out-of-pocket expenses
» requiring pass-through of all PBM rebates and discounts
» eliminating the manufacturer coverage discount program
» eliminating spread pricing in both commercial and government markets
» changing the financial responsibilities between government and insurers in the » requiring increased public transparency through reporting of PBM costs, fees, and catastrophic phase rebate information to plan sponsors and government advisory committees.
By the end of the year, these committee bills had yet to be combined and brought to the Senate floor for a vote.3 The House of Representatives took up HR3, its major drug-pricing bill, in the fall of 2019. That bill included direct government negotiation of the top 250 high-cost drugs that had little or no competition. Prices would be capped at the upper limit of 120% of an average international pricing index for drugs in six major countries. The bill also included establishing an inflation rebate in the Medicare program and limiting consumer out-of-pocket costs.4 Together, these House and Senate bills highlighted the broad range of drug-pricing issues policymakers were grappling with across the drug supply chain over the past year and are indicative of the momentum behind efforts to increase competition, limit consumer costs, and lower drug prices in this country through legislative action. It is expected that these policy issues will continue to be debated throughout the remainder of the 116th Congress.
Trump Administration Moves Forward on Drug Pricing but Finds Hurdles Along the Way The Trump administration has also moved aggressively on drug-pricing issues in 2019 through the regulatory process, but it has run into numerous hurdles over the course of the year. As part of its May 2018 Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs, the administration proposed to require that all rebates in government programs be passed back to consumers at the point of sale. Given that Medicare premiums would rise, since rebate dollars are used to reduce premiums, and the estimated cost of this proposed rule was substantial, the administration pulled the rebate rule in July 2019.5 The Trump administration also proposed a rule in late 2018 that would require drug manufacturers to list the cost of a 30-day supply of drugs in its direct-to-consumer advertisements. The final rule was to take effect in July 2019, but a federal court struck down the rule a week before it was to take effect.6 The administration also issued an advance notice of proposed rule-making that intended to create a national demonstration model to test for paying Part B drugs through an international pricing model based on prices from select countries. The White House, in announcing this national demonstration, stated that it hoped to issue a proposed rule in spring 2019, with a program start date in spring 2020. The proposed rule has been under review at the Office of Management and Budget since June 2019.7 Despite these obstacles, it is clear from the actions taken throughout the year that the administration remains committed to addressing drug-pricing issues through use of its regulatory authority in all aspects of the drug supply chain.
HHS and FDA Release Drug Importation Regulations On Dec. 18, 2019, the U.S. Department of Health and Human Services (HHS) and the U.S. Food and Drug Administration (FDA) released proposed regulations and guidance aimed at facilitating the importation of certain drugs from Canada and, potentially, other foreign countries. This proposal (which builds on the FDA’s Safe Importation Action Plan released summer 2019) identifies a number of potential pathways for the importation of lower-cost prescription drugs. The public comment period closed March 9, 2020. HR987 passed U.S. House of Representatives on May 16, 2019, 234-183. S1895 passed Senate Health Education Labor Pensions Committee on June 26, 2019; S1416, S440, S1224, and S1227 passed Senate Judiciary Committee on June 28, 2019; S2543 passed Senate Finance Committee on July 25, 2019. 4 HR3 passed Energy and Commerce Committee on Oct. 17, 2019; passed Education and Labor Committee on Oct. 17, 2019; passed Ways and Means Committee on Oct. 23, 2019. 5 Abutaleb, Yasmeen et al. “Trump Kills Key Drug Price Proposal He Once Embraced.” Washington Post, July 11, 2019, https://www.washingtonpost.com/business/economy/white-house-kills-key-drug-pricing-rule-to-eliminate-hidden-rebates/2019/07/11/ ff595192-a3de-11e9-bd56-eac6bb02d01d_story.html. 6 Thomas, Katie, and Katie Rogers. “Judge Blocks Trump Rule Requiring Drug Companies to List Prices in TV Ads.” New York Times, July 8, 2019, https://www.nytimes.com/2019/07/08/health/drug-prices-tv-ads-trump.html. 7 Cohrs, Rachel, “Azar says Trump wants more aggressive international drug-pricing demo.” Modern Healthcare, Nov. 13, 2019, https://www.modernhealthcare.com/policy/azar-says-trump-wants-more-aggressive-international-drug-pricing-demo. 2 3
29
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
According to analysis of FDA data, 2019 saw a significant number of specialty drug approvals — 54 total, 31 of them new molecular entities. Almost 60% of the total specialty drugs approved were on the medical benefit, further emphasizing the need for strong management strategies in medical pharmacy. The pipeline drug outlook provides a high-level outline of drugs with anticipated FDA approval through 2021 and the impact that specialty drugs will have on the industry in the upcoming one to two years (see figure 58). The segment of pipeline drugs anticipated to have $1 billion in spend is expected to increase 15%, from 33 drugs in 2018 to 38 in 2024 (see figure 59).
PIPELINE DRUG LIST
For more detailed drug pipeline information, visit magellanrx.com/pipeline.
The pipeline drug list is an aerial outline of drugs with anticipated FDA approval through 2021. It is not intended to be a comprehensive inventory of all drugs in the pipeline; emphasis is placed on drugs in high-impact categories. Investigational 8 FIGURE 58:drugs PIPELINE OUTLOOK THROUGH with DRUG a Complete Response Letter2021 (CRL) and those that have been withdrawn from development are also noted. APPLICATION SUBMITTED TO THE FDA
FIGURE 59: BILLION-DOLLAR DRUGS FORECAST 9
38
IN PHASE 3 TRIALS
37 57% 43% 30% 25% 15% 5%
38
37
63% 37% 36 % 15%
35
35
2019
2020
15%
% change 2018-2024
9%
33
Specialty
Traditional
Priority Review
Orphan Drug
Breakthrough Therapy
Biosimilar 2018
2021
2022
2023
2024
MRx Pipeline Report January 2020. https://www1.magellanrx.com/publications/mrx-pipeline/. Accessed February 2020. Data provided by Evaluate Ltd. EvaluatePharma®.
8 9
drug names appear in �Specialty magenta throughout the publication.
21 | magellanrx.com
2019 / MAGELLANRX.COM/TRENDREPORT
30
2019 REPORT METHODOLOGY AND DEMOGRAPHICS The methodology for the 10th edition of the Magellan Rx Management Medical Pharmacy Trend Report™ was developed with original guidance from our payer advisory board, as well as reader feedback on our previous trend reports. This report includes a combination of primary and secondary research methodologies to deliver a comprehensive view of payer perceptions and health plan actions related to provider-administered infused or injected drugs paid under the medical benefit, also referred to as medical pharmacy or medical benefit drugs. These medical benefit drugs are commonly used to treat diseases such as cancer, autoimmune disorders, and immunodeficiencies.
Payer Survey
190M
PAYERS (33 WITH MEDICARE LIVES)
MEDICAL PHARMACY LIVES
74%
26%
PHARMACY DIRECTORS
MEDICAL DIRECTORS, CEOs, IR, NETWORK DIRECTORS
RESPONDENT PLAN SIZE
COMMERCIAL 35%
Medical benefit drug utilization and trend data were collected through secondary analyses of commercial, Medicare, and Medicaid health plan medical paid claims data for the most recent calendar years. Claims data were analyzed for medical pharmacy utilization across 941 HCPCS codes and several outpatient sites of service. Vaccines and radiopharmaceuticals were excluded from the analyses. Year over year, shifts in claims data have occurred due to adjustments. Administration codes were analyzed separately in only one analysis; their utilization was not included in any other analyses. Most analyses compared calendar years 2017 and 2018. In some cases, the past five years were analyzed to show a longer period of year-over-year spend and trend. Year over year, shifts in claims data information have occurred due to adjustments. FIGURE 60: MEDICAL BENEFIT DRUG EXAMPLES FOR THERAPEUTIC CLASSES IN PAYER SURVEY
RESPONDENT SAMPLE
54
Health Plan Claims Data
Drug Category
Example Drugs
Antihemophilic Factors
Advate, Alphanate, BeneFix, NovoSeven, Recombinate, Xyntha
Asthma
Cinqair, Fasenra, Nucala, Xolair
Biologic Drugs for Autoimmune Disorders
Actemra, Cimzia, Entyvio, Orencia, Remicade, Simponi ARIA, Stelara
Botulinum Toxins
Botox, Dysport, Myobloc, Xeomin
Immune Globulin
Gammagard Subcutaneous (SQ), Gamunex, Hizentra, HyQvia
Multiple Sclerosis (Infusion Only)
Lemtrada, Ocrevus, Tysabri
Oncology
Avastin, Cyramza, Erbitux, Herceptin, Rituxan, Vectibix
Oncology Immunotherapy
Bavencio, Imfinzi, Keytruda, Libtayo, Opdivo, Tecentriq
Oncology Support
Antiemetics, CSFs, ESAs, folinic acids, octreotide/Sandostatin
Ophthalmic Injections
bevacizumab, Eylea, Lucentis, Macugen
Viscosupplementation
Euflexxa, Gel-One, Hyalgan, Monovisc, Orthovisc, Supartz, Synvisc
FIGURE 61: REGIONAL PLANS: GEOGRAPHIC DISPERSION OF LIVES
MEDICARE
(n=45; 35 million covered lives)
39%
>1M lives
>1M lives
65%
61%
<1M lives
<1M lives
27%
22% 27%
West
24%
South
Forecasting powered by
Midwest Northeast Data provided by Evaluate Ltd. EvaluatePharma®.
31
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
APPENDIX FIGURE 62: MEDICAL PHARMACY ALLOWED AMOUNT PMPM 2014-2018*
2014
2014-2015 % Change
2015
2015-2016 % Change
2016
2016-2017 % Change
2017
2017-2018 % Change
2018
COMMERCIAL
Home Infusion
$3.06
20%
$3.66
15%
$4.22
38%
$5.82
16%
$6.77
Hospital OP
$10.41
3%
$10.70
22%
$13.02
14%
$14.83
9%
$16.17
Physician Office
$6.47
13%
$7.31
13%
$8.25
11%
$9.12
9%
$9.90
Total
$19.94
9%
$21.68
18%
$25.49
17%
$29.77
10%
$32.83
Home Infusion
$4.04
-23%
$3.12
-1%
$3.10
32%
$4.10
29%
$5.27
Hospital OP
$19.39
-5%
$18.49
2%
$18.79
8%
$20.32
3%
$21.01
Physician Office
$20.48
18%
$24.24
2%
$24.67
33%
$32.69
8%
$35.20
Total
$43.90
4%
$45.86
2%
$46.56
23%
$57.11
8%
$61.47
Home Infusion
$1.10
-6%
$1.03
-0.1%
$1.02
0.1%
$1.03
12%
$1.15
Hospital OP
$2.62
50%
$3.93
5%
$4.11
34%
$5.52
9%
$6.04
Physician Office
$2.41
9%
$2.62
27%
$3.33
12%
$3.72
0.5%
$3.74
Total
$6.13
24%
$7.58
12%
$8.46
21%
$10.26
7%
$10.93
MEDICARE
MEDICAID
*Due to rounding, column totals may not add up exactly.
2019 / MAGELLANRX.COM/TRENDREPORT
32
APPENDIX FIGURE 63: 2018 COMMERCIAL COST TRENDS BY DISEASE STATE OF DRUG CATEGORY*
Rank
Therapy
2017 PMPM
2018 PMPM
20172018 % Change
% of Total PMPM
Cost per Claim
Members per 1,000
% of Members
ASP Index
AWP Index
Rank
16
1
Oncology
$10.06 $11.42
14%
35%
$2,738.13
1.84
1.7%
1.70
1.26
2
BDAID: Crohnâ&#x20AC;&#x2122;s Disease/Ulcerative Colitis
$3.05
$3.28
8%
10%
$7,314.92
0.38
0.3%
1.67
1.03
3
Immune Globulin
$2.31
$2.66
15%
8%
$3,990.37
0.15
0.1%
1.73
0.87
4
Colony-Stimulating Factors
$2.06
$2.10
2%
6%
$5,032.12
0.42
0.4%
1.69
0.98
5
Multiple Sclerosis
$0.89
$1.54
73%
5%
$16,897.00
0.10
0.1%
1.61
1.27
6
Antihemophilic Factor
$1.61
$1.20
-25%
4%
$15,880.46
0.01
0.0%
1.97
1.25
7
BDAID: Rheumatoid Arthritis
$1.23
$1.18
-4%
4%
$4,964.41
0.18
0.2%
1.35
0.94
8
Enzyme Replacement Therapy
$0.73
$0.74
1%
2%
$19,514.94
0.01
0.0%
1.71
1.22
9
Hematology
$0.61
$0.71
16%
2%
$10,694.09
0.02
0.0%
1.50
1.23
10
Asthma/COPD
$0.52
$0.60
15%
2%
$527.61
2.39
2.2%
1.54
1.01
11
Ophthalmic Injections
$0.49
$0.54
10%
2%
$1,145.95
0.49
0.5%
1.21
0.85
12
Other
$0.40
$0.52
30%
2%
$141.42
8.48
7.9%
2.07
1.20
13
Infectious Disease
$0.49
$0.51
4%
2%
$91.41
9.37
8.7%
2.36
0.84
14
Botulinum Toxins
$0.37
$0.44
19%
1%
$1,088.53
0.63
0.6%
1.24
0.99
15
Antiemetics
$0.40
$0.43
8%
1%
$124.72
8.85
*Due to rounding, column totals may not add up exactly.
33
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
8.2%
2.56
2017 PMPM
2018 PMPM
20172018 % Change
% of Total PMPM
Cost per Claim
Members per 1,000
% of Members
ASP Index
AWP Index
Contraceptives
$0.38
$0.43
13%
1%
$612.72
2.49
2.3%
25.56
0.89
17
BDAID: Psoriasis/ Psoriatic Arthritis
$0.54
$0.43
-20%
1%
$7,377.39
0.05
0.0%
1.39
0.82
18
Unclassified
$0.62
$0.41
-34%
1%
$235.08
2.88
2.7%
-
-
19
CNS Agents: Rare Diseases
$0.02
$0.33
1975%
1%
$37,679.26
0.00
0.0%
-
0.72
20
Iron, Intravenous
$0.27
$0.32
19%
1%
$663.44
0.73
0.7%
2.13
1.19
21
Pain Management
$0.28
$0.32
14%
1%
$38.63
14.83
13.8%
3.37
2.01
22
Gastrointestinal: Chemoprotectant
$0.23
$0.28
22%
1%
$7,847.37
0.03
0.0%
1.68
1.27
23
Hereditary Angioedema
$0.20
$0.24
20%
1%
$32,269.81
0.00
0.0%
1.61
0.90
24
Viscosupplementation
$0.23
$0.23
0%
1%
$350.69
0.93
0.9%
1.36
0.45
25
Fluids
$0.09
$0.18
100%
1%
$48.77
8.04
7.5%
14.70
3.93
26
BDAID: Other
$0.15
$0.18
20%
1%
$6,745.93
0.03
0.0%
1.86
1.04
27
BDAID: Systemic Lupus Erythematosus
$0.21
$0.15
-29%
0%
$3,689.46
0.02
0.0%
1.40
1.13
28
Alpha-1 Proteinase Inhibitor
$0.11
$0.15
36%
0%
$4,862.31
0.00
0.0%
0.91
0.61
29
Sedatives/Anesthesia
$0.09
$0.15
67%
0%
$39.15
10.09
9.4%
18.19
5.17
30
Corticosteroids
$0.12
$0.15
25%
0%
$13.84
27.47
25.5%
1.96
1.38
Therapy
1.38
FIGURE 64: 2018 MEDICARE COST TRENDS BY DISEASE STATE OF DRUG CATEGORY*
Rank
Therapy
2017 PMPM
2018 PMPM
$25.83 $28.10
20172018 % Change
% of Total PMPM
Cost per Claim
Members per 1,000
% of Members
ASP Index
AWP Index
Rank
9%
45.7%
$1,704.35
8.67
4.8%
1.03
0.75
16
2017 PMPM
2018 PMPM
20172018 % Change
% of Total PMPM
Cost per Claim
Members per 1,000
% of Members
ASP Index
AWP Index
Botulinum Toxins
$0.50
$0.66
32%
1.1%
$820.29
1.49
0.8%
1.02
0.82
Therapy
1
Oncology
2
Ophthalmic Injections
$6.97
$7.89
13%
12.8%
$948.55
8.09
4.5%
1.03
0.82
17
Antiemetics
$0.64
$0.60
-6%
1.0%
$132.93
4.85
2.7%
1.13
0.60
3
Immune Globulin
$3.38
$3.62
7%
5.9%
$2,798.63
0.40
0.2%
1.09
0.54
18
Unclassified
$0.74
$0.59
-20%
1.0%
$450.79
2.03
1.1%
0.00
0.00
4
Colony-Stimulating Factors
$3.77
$3.56
-6%
5.8%
$2,580.79
1.64
0.7%
1.04
0.61
19
Iron, Intravenous
$0.54
$0.56
4%
0.9%
$346.59
2.08
1.2%
1.06
0.58
20
Infectious Disease
$0.65
$0.54
-17%
0.9%
$65.46
12.54
6.9%
1.37
0.44
5
BDAID: Rheumatoid Arthritis
$2.45
$2.26
-8%
3.7%
$3,370.21
0.59
0.3%
0.93
0.65 21
Antihemophilic Factor
$1.12
$0.51
-54%
0.8%
$26,375.05
0.01
0.0%
4.86
3.30
6
Multiple Sclerosis
$0.98
$1.48
51%
2.4%
$10,012.94
0.14
0.1%
0.96
0.76
22
Corticosteroids
$0.31
$0.33
6%
0.5%
$11.28
63.48
35.1%
1.08
0.79
7
ErythropoiesisStimulating Agents
$1.12
$1.10
-2%
1.8%
$618.43
1.17
0.6%
1.09
0.52
23
BDAID: Psoriasis/ Psoriatic Arthritis
$0.29
$0.31
7%
0.5%
$4,554.83
0.07
0.0%
0.89
0.52
8
Hematology
$1.10
$1.10
0%
1.8%
$4,953.04
0.07
0.0%
1.01
0.79 24
Alpha-1 Proteinase Inhibitor
$0.21
$0.22
5%
0.4%
$2,717.71
0.01
0.0%
0.43
0.28
25
Cardiovascular Agent
$0.33
$0.20
-39%
0.3%
$73.54
4.04
2.2%
1.18
0.81
26
Enzyme Replacement Therapy
$0.04
$0.14
269%
0.2%
$12,841.61
0.00
0.0%
0.78
0.63
27
BDAID: Ankylosing Spondylitis
$0.14
$0.12
-14%
0.2%
$3,991.26
0.04
0.0%
0.97
0.55
28
BDAID: Systemic Lupus Erythematosus
$0.09
$0.11
22%
0.2%
$2,582.94
0.02
0.0%
1.03
0.83
29
Transplant
$0.02
$0.09
419%
0.2%
$49.63
0.43
0.2%
0.33
0.10
30
BDAID: Other
$0.12
$0.09
-25%
0.1%
$3,846.42
0.04
0.0%
1.05
0.59
9
Other
10
BDAID: Crohnâ&#x20AC;&#x2122;s Disease/Ulcerative Colitis
$0.98
Viscosupplementation
$0.97
11
$0.83
$1.09
$1.03
$0.97
31%
5%
0%
1.8%
1.7%
1.6%
$81.04
$4,478.61
$275.22
23.95
0.21
5.78
13.2%
0.1%
3.2%
1.00
1.01
1.08
0.62
0.64
0.37
12
Asthma/COPD
$0.87
$0.97
11%
1.6%
$153.14
8.01
4.4%
0.83
0.34
13
Gastrointestinal: Chemoprotectant
$0.73
$0.94
29%
1.5%
$4,987.88
0.11
0.1%
1.01
0.76
14
Pulmonary Arterial Hypertension
$0.23
$0.85
264%
1.4%
$8,828.78
0.12
0.0%
0.83
0.66
Bone Resorption Inhibitors (Osteoporosis)
$0.67
15
$0.82
22%
1.3%
$838.31
3.34
1.8%
1.01
0.69
*Due to rounding, column totals may not add up exactly.
2019 / MAGELLANRX.COM/TRENDREPORT
34
APPENDIX FIGURE 65: 2018 MEDICAID COST TRENDS BY DISEASE STATE OF DRUG CATEGORY*
Rank
Therapy
2017 PMPM
2018 PMPM
20172018 % Change
% of Total PMPM
Cost per Claim
Members per 1,000
% of Members
ASP Index
AWP Index
Rank
2017 PMPM
2018 PMPM
20172018 % Change
% of Total PMPM
Cost per Claim
Members per 1,000
% of Members
ASP Index
AWP Index
16
Other
$0.12
$0.15
25%
1.3%
$55.70
5.31
7.2%
1.13
0.72
17
Ophthalmic Injections
$0.07
$0.14
100%
1.2%
$575.77
0.46
0.5%
0.92
0.74
18
Corticosteroids
$0.13
$0.13
0%
1.2%
$16.38
21.33
28.7%
1.39
1.02
19
Iron, Intravenous
$0.12
$0.13
8%
1.2%
$553.21
0.40
0.5%
1.43
0.79
Therapy
1
Oncology
$3.57
$3.66
3%
33.5%
$1,838.63
0.80
1.1%
1.15
0.86
2
Colony-Stimulating Factors
$0.90
$0.80
-11%
7.3%
$4,188.00
0.19
0.3%
1.40
0.82
3
BDAID: Crohnâ&#x20AC;&#x2122;s Disease/Ulcerative Colitis
$0.67
$0.66
-1%
6.0%
$6,150.26
0.11
0.2%
1.54
0.92
4
Contraceptives
$0.49
$0.61
24%
5.6%
$362.81
5.77
7.8%
8.73
0.87
20
Hereditary Angioedema
$0.09
$0.12
33%
1.1%
$10,783.23
0.00
0.0%
1.09
0.84
5
CNS Agents: Rare Diseases
-
$0.55
-
5.0%
$43,162.48
0.01
0.0%
-
0.80
21
Progestins
$0.35
$0.10
-71%
0.9%
$925.86
0.10
0.1%
-
0.87
6
Immune Globulin
$0.60
$0.49
-18%
4.5%
$2,870.01
0.06
0.1%
1.54
0.79
22
BDAID: Psoriasis/ Psoriatic Arthritis
$0.08
$0.10
25%
0.9%
$6,873.11
0.02
0.0%
1.41
0.83
7
Multiple Sclerosis
$0.26
$0.38
46%
3.4%
$9,270.59
0.04
0.1%
1.20
0.93
23
Unclassified
$0.22
$0.09
-59%
0.8%
$475.86
0.49
0.7%
-
-
8
Enzyme Replacement Therapy
$0.27
$0.36
33%
3.3%
$13,596.51
0.01
0.0%
0.56
0.43
24
CNS: Skeletal Muscle Relaxants
$0.07
$0.08
14%
0.8%
$482.37
0.47
0.6%
1.62
1.07
9
Botulinum Toxins
$0.27
$0.31
15%
2.8%
$1,152.24
0.51
0.7%
1.16
0.93
25
BDAID: Other
$0.08
$0.08
0%
0.7%
$5,198.09
0.02
0.0%
1.57
0.87
10
BDAID: Rheumatoid Arthritis
$0.29
$0.28
-3%
2.5%
$3,583.28
0.06
0.1%
1.14
0.77
26
Viscosupplementation
$0.05
$0.08
60%
0.7%
$277.10
0.51
0.7%
1.21
0.42
11
Hematology
$0.22
$0.28
27%
2.5%
$4,974.88
0.01
0.0%
1.16
0.95
27
Pain Management
$0.07
$0.06
-14%
0.6%
$15.59
9.10
12.3%
1.63
0.96
12
Antihemophilic Factor
$0.15
$0.26
73%
2.4%
$13,945.15
0.01
0.0%
1.12
0.71
28
Cardiovascular Agent
$0.07
$0.05
-29%
0.5%
$65.19
1.33
1.8%
1.58
1.15
13
Infectious Disease
$0.25
$0.23
-8%
2.1%
$50.35
8.35
11.2%
1.46
0.48
29
ErythropoiesisStimulating Agents
$0.07
$0.05
-29%
0.4%
$719.44
0.08
0.1%
1.53
0.72
14
Asthma/COPD
$0.17
$0.22
29%
2.0%
$220.13
3.54
4.8%
1.27
0.90 30
Gastrointestinal: Chemoprotectant
$0.05
$0.04
-20%
0.4%
$4,062.14
0.01
0.0%
1.05
0.79
15
Antiemetics
$0.25
$0.19
-24%
1.7%
$71.49
6.14
*Due to rounding, column totals may not add up exactly.
35
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
8.3%
2.15
1.18
FIGURE 66: COMMERCIAL TOP 25 DRUGS COST TRENDS 2017-2018 PMPM
COST PER PATIENT
COST PER CLAIM
MEMBERS PER 1,000
ASP INDEX
AWP INDEX
Rank
Change in rank
HCPCS
Brand
2017
2018
% Change
2017
2018
% Change
2017
2018
% Change
2018
2018
2018
1
J1745
Remicade
$3.05
$2.95
-3.4%
$42,073
$35,572
-15.5%
$6,880
$6,603
-4.0%
0.37
1.7
0.9
2
J2505
Neulasta
$1.96
$2.00
2.1%
$28,505
$29,465
3.4%
$6,879
$7,336
6.6%
0.34
1.7
1.0
3
J9355
Herceptin
$1.39
$1.49
7.3%
$60,738
$63,454
4.5%
$5,360
$5,351
-0.2%
0.12
1.6
1.3
4
J9310
Rituxan
$1.52
$1.40
-7.8%
$42,189
$39,388
-6.6%
$10,037
$9,996
-0.4%
0.18
1.5
1.2
5
J9035
Avastin
$1.14
$1.17
2.3%
$27,982
$28,011
0.1%
$4,277
$4,646
8.6%
0.21
1.7
1.3
6
J9299
Opdivo
$0.70
$1.05
50%
$62,717
$79,441
26.7%
$6,356
$9,663
52.0%
0.07
1.6
1.3
7
J3380
Entyvio
$0.69
$0.92
32.6%
$40,045
$39,117
-2.3%
$7,946
$8,055
1.4%
0.10
1.5
1.1
8
J2350
Ocrevus
-
$0.85
-
-
$77,935
-
-
$37,929
-
0.05
1.6
1.3
9
J9271
Keytruda
$0.47
$0.84
78.9%
$73,197
$76,134
4.0%
$13,081
$12,895
-1.4%
0.06
1.5
1.2
10
J1561
Gamunex-C/Gammaked
$0.73
$0.82
12.7%
$64,384
$53,589
-16.8%
$4,890
$4,838
-1.1%
0.05
1.9
1.1
11
J9306
Perjeta
$0.55
$0.69
27.4%
$53,267
$58,611
10.0%
$7,622
$7,845
2.9%
0.07
1.6
1.2
12
J1569
Gammagard Liquid
$0.57
$0.64
12.0%
$46,594
$41,407
-11.1%
$4,469
$4,751
6.3%
0.05
1.7
0.8
13
J1300
Soliris
$0.48
$0.58
20.6%
$490,550
$489,172
-0.3%
$34,165
$33,056
-3.2%
0.00
1.5
1.2
14
J2323
Tysabri
$0.71
$0.57
-19.3%
$71,747
$65,965
-8.1%
$8,499
$8,757
3.0%
0.04
1.6
1.2
15
J0897
Xgeva/Prolia
$0.46
$0.50
8.7%
$5,439
$5,369
-1.3%
$2,469
$2,431
-1.6%
0.41
1.6
1.2
16
J2357
Xolair
$0.44
$0.46
5.8%
$20,425
$20,342
-0.4%
$1,048
$1,094
4.4%
0.08
1.2
1.0
17
J0585
Botox
$0.36
$0.42
17.0%
$2,928
$3,031
3.5%
$15,827
$16,743
5.8%
0.59
1.2
1.0
18
J7192
Factor VIII (Recombinant)
$0.56
$0.40
-28.8%
$229,554
$159,733
-30.4%
$4,406
$4,308
-2.2%
0.01
2.0
1.4
19
J1459
Privigen
$0.27
$0.39
44.8%
$48,806
$42,589
-12.7%
$47,599
$29,815
-37.4%
0.03
1.8
0.8
20
J9228
Yervoy
$0.36
$0.36
0%
$184,736
$110,246
-40.3%
$17,859
$18,638
4.4%
0.02
1.5
1.2
21
J3357
Stelara
$0.42
$0.35
-15.7%
$49,102
$43,411
-11.6%
$1,592
$1,693
6.4%
0.03
1.5
1.0
22
J1559
Hizentra
$0.21
$0.34
57.4%
$55,011
$43,517
-20.9%
$2,226
$2,215
-0.5%
0.02
1.6
0.7
23
J0178
Eylea
$0.31
$0.32
4.5%
$11,805
$11,165
-5.4%
$6,959
$6,851
-1.6%
0.14
1.1
0.9
24
J9305
Alimta
$0.28
$0.32
11.9%
$38,750
$41,642
7.5%
$4,383
$4,505
2.8%
0.05
1.5
1.2
25
J0129
Orencia
$0.29
$0.30
3.9%
$32,435
$31,469
-3.0%
$2,193
$2,430
10.8%
0.05
1.2
1.1
2019 / MAGELLANRX.COM/TRENDREPORT
36
APPENDIX FIGURE 67: MEDICARE TOP 25 DRUGS COST TRENDS 2017-2018 PMPM
COST PER PATIENT
COST PER CLAIM
MEMBERS PER 1,000
ASP INDEX
AWP INDEX
Rank
Change in rank
HCPCS
Brand
2017
2018
% Change
2017
2018
% Change
2017
2018
% Change
2018
2018
2018
1
J0178
Eylea
$3.91
$4.47
14.3%
$9,832
$9,185
-6.6%
$1,878
$1,910
1.7%
2.36
0.9
0.8
2
J9271
Keytruda
$2.12
$4.09
92.9%
$43,561
$53,470
22.7%
$8,204
$9,017
9.9%
0.45
1.0
0.8
3
J9299
Opdivo
$3.16
$3.72
17.7%
$47,097
$53,516
13.6%
$4,416
$6,262
41.8%
0.42
1.0
0.8
4
J2505
Neulasta
$3.52
$3.34
-5.1%
$14,635
$16,414
12.2%
$4,125
$4,466
8.3%
1.24
1.0
0.6
5
J9310
Rituxan
$3.68
$3.19
-13.3%
$23,996
$23,699
-1.2%
$5,206
$5,825
11.9%
0.61
0.9
0.8
6
J2778
Lucentis
$2.61
$2.91
11.5%
$10,164
$9,690
-4.7%
$1,774
$1,820
2.6%
1.46
1.0
0.8
7
J0897
Xgeva/Prolia
$2.14
$2.45
14.5%
$2,814
$2,223
-21.0%
$1,324
$1,364
3.0%
3.78
1.1
0.8
8
J9035
Avastin
$2.32
$2.19
-5.5%
$3,303
$2,597
-21.4%
$696
$633
-9.0%
5.11
0.9
0.8
9
J9355
Herceptin
$1.91
$1.91
0%
$38,433
$42,005
9.3%
$3,164
$3,162
-0.1%
0.28
1.0
0.8
10
J1745
Remicade
$1.98
$1.56
-21.2%
$21,102
$17,573
-16.7%
$3,650
$3,694
1.2%
0.40
0.9
0.6
11
J1569
Gammagard Liquid
$1.18
$1.37
16.1%
$29,507
$29,546
0.1%
$3,191
$3,441
7.9%
0.17
1.1
0.5
12
J9305
Alimta
$1.04
$0.99
-4.8%
$23,685
$24,038
1.5%
$3,780
$3,948
4.4%
0.25
1.0
0.8
13
J1561
Gamunex-C/Gammaked
$0.74
$0.95
28.3%
$33,367
$29,909
-10.4%
$2,735
$3,224
17.9%
0.12
1.1
0.6
14
J9041
Velcade
$1.05
$0.95
-9.5%
$21,586
$19,661
-8.9%
$924
$975
5.5%
0.29
1.0
0.8
15
J9145
Darzalex
$0.80
$0.94
17.5%
$56,034
$56,733
1.2%
$4,362
$4,339
-0.5%
0.10
1.0
0.8
16
J2353
Sandostatin
$0.73
$0.93
27.3%
$34,917
$40,480
15.9%
$4,640
$5,301
14.2%
0.10
1.0
0.8
17
J1300
Soliris
$0.59
$0.81
37.2%
$331,127
$285,026
-13.9%
$20,695
$21,698
4.8%
0.01
0.9
0.8
18
J2350
Ocrevus
-
$0.77
-
-
$40,017
-
-
$22,182
-
0.08
0.9
0.8
19
J9217
Eligard/Lupron Depot
$0.64
$0.70
9.3%
$1,666
$1,688
1.3%
$804
$817
1.5%
1.92
1.0
0.4
20
J9047
Kyprolis
$0.52
$0.69
32.6%
$38,860
$57,264
47.4%
$1,386
$1,622
17.0%
0.07
1.1
0.8
21
J0129
Orencia
$0.76
$0.66
-13.1%
$22,998
$20,905
-9.1%
$3,073
$3,320
8.0%
0.15
0.9
0.9
22
J9264
Abraxane
$0.71
$0.66
-7.0%
$16,918
$17,657
4.4%
$1,448
$1,563
7.9%
0.23
1.0
0.7
23
J9306
Perjeta
$0.58
$0.63
8.6%
$36,171
$39,501
9.2%
$4,802
$4,938
2.8%
0.10
1.0
0.8
24
J9228
Yervoy
$0.40
$0.61
52.5%
$80,624
$58,615
-27.3%
$23,158
$15,707
-32.2%
0.06
0.9
0.8
25
J0885
Procrit
$0.59
$0.59
0%
$3,963
$4,097
3.4%
$465
$495
6.5%
0.68
1.1
0.7
37
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
FIGURE 68: MEDICAID TOP 25 DRUGS COST TRENDS 2017-2018 PMPM
COST PER PATIENT
COST PER CLAIM
MEMBERS PER 1,000
ASP INDEX
AWP INDEX
Rank
Change in rank
HCPCS
Brand
2017
2018
% Change
2017
2018
% Change
2017
2018
% Change
2018
2018
2018
1
J1745
Remicade
$0.83
$0.77
-7.3%
$32,391
$24,581
-24.1%
$5,809
$5,651
-2.7%
0.13
1.5
0.9
2
J2505
Neulasta
$0.87
$0.77
-11.5%
$21,509
$20,367
-5.3%
$6,021
$6,059
0.6%
0.16
1.4
0.8
3
J9271
Keytruda
$0.24
$0.42
75%
$51,855
$49,741
-4.1%
$10,444
$9,652
-7.6%
0.05
1.1
0.9
4
J9035
Avastin
$0.34
$0.39
14.7%
$13,162
$7,193
-45.4%
$2,534
$1,761
-30.5%
0.31
1.2
0.9
5
J9299
Opdivo
$0.34
$0.39
13.4%
$49,838
$41,553
-16.6%
$5,397
$6,315
17.0%
0.05
1.1
0.9
6
J9355
Herceptin
$0.56
$0.39
-31.2%
$47,934
$34,468
-28.1%
$4,603
$3,416
-25.8%
0.06
1.1
0.9
7
J2326
Spinraza
-
$0.28
-
-
$247,597
-
-
$92,849
-
0.01
-
0.7
8
J0585
Botox
$0.24
$0.28
12.9%
$3,200
$2,811
-12.2%
$1,302
$1,125
-13.6%
0.48
1.1
0.9
9
J1428
Exondys
-
$0.27
-
-
$1,104,165
-
-
$25,095
-
0.00
-
0.9
10
J7307
Implanon
$0.21
$0.24
11.5%
$982
$927
-5.6%
$963
$915
-4.9%
1.27
-
0.9
11
J1300
Soliris
$0.18
$0.24
34.6%
$242,408
$236,569
-2.4%
$24,513
$27,928
13.9%
0.01
1.2
1.0
12
J2323
Tysabri
$0.24
$0.23
-6.0%
$57,184
$39,864
-30.3%
$7,596
$6,806
-10.4%
0.02
1.2
0.9
13
J1561
Gamunex-C/Gammaked
$0.25
$0.22
-9.7%
$32,422
$31,386
-3.2%
$3,383
$3,077
-9.0%
0.03
1.7
1.0
14
J9310
Rituxan
$0.19
$0.21
11.5%
$17,710
$15,247
-13.9%
$4,936
$4,906
-0.6%
0.08
0.8
0.7
15
J9306
Perjeta
$0.22
$0.19
-10.0%
$40,817
$35,255
-13.6%
$6,332
$5,977
-5.6%
0.03
1.2
1.0
16
J7298
Mirena
$0.15
$0.19
26.4%
$946
$944
-0.2%
$912
$928
1.7%
1.32
17
J2357
Xolair
$0.15
$0.19
20.3%
$20,812
$17,753
-14.7%
$1,942
$2,059
6.0%
0.07
1.1
0.9
18
J1743
Elaprase
$0.11
$0.16
45%
$346,722
$451,671
30.3%
$20,100
$19,139
-4.8%
0.00
1.2
1.0
0.9
19
J7186
Alphanate
-
$0.16
-
-
$367,799
-
-
$61,300
-
0.00
1.1
0.7
20
J2350
Ocrevus
-
$0.14
-
-
$41,623
-
-
$20,630
-
0.01
1.1
0.9
21
J9305
Alimta
$0.14
$0.14
0%
$30,729
$25,043
-18.5%
$4,622
$4,439
-4.0%
0.03
1.1
0.9
22
J0897
Xgeva/Prolia
$0.15
$0.13
-9.3%
$6,027
$5,506
-8.6%
$2,133
$2,170
1.8%
0.10
1.3
0.9
23
J9042
Adcetris
$0.08
$0.12
45.1%
$125,217
$101,806
-18.7%
$18,901
$13,883
-26.5%
0.01
1.1
0.9
24
J3380
Entyvio
$0.08
$0.10
22.3%
$30,416
$21,358
-29.8%
$7,604
$6,346
-16.5%
0.02
1.2
0.9
25
J1569
Gammagard Liquid
$0.14
$0.10
-30.1%
$20,807
$18,341
-11.9%
$2,605
$2,906
11.6%
0.02
1.3
0.6
2019 / MAGELLANRX.COM/TRENDREPORT
38
Kanuma Naglazyme
39 Vimizim Firazyr Exondys Kymriah Elaprase Soliris Lumizyme Yescarta
Xyntha Koate Vpriv Soliris Cerezyme
PMPM
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
Spinraza Folotyn
PMPM Besponsa Blincyto Ventavis
Exondys Elaprase Cinryze Alphanate Vimizim Naglazyme Adagen Spinraza Soliris
PMPM
Cerezyme
$247,597
$254,301
$291,587
$301,910
$367,799
$231,910
ANNUAL ALLOWED PER PATIENT
$393,327
$451,671
$1,104,165
FIGURE 70: 2018 MEDICARE 10 HIGHEST-COST DRUGS
$236,569
$147,321
$170,398
$205,364
$207,601
$268,175
$271,614
ANNUAL ALLOWED PER PATIENT
$285,026
$324,414
$959,837
FIGURE 69: 2018 COMMERCIAL 10 HIGHEST-COST DRUGS
$532,739
$450,326
$458,771
$489,172
$492,726
$498,750
$500,722
$517,888
$645,277
$876,732
$921,984
APPENDIX FIGURE 71: 2018 MEDICAID 10 HIGHEST-COST DRUGS
ANNUAL ALLOWED PER PATIENT
$0.06 $0.06 $0.04 $0.05 $0.07 $0.00 $0.07 $0.58 $0.06 $0.01 $0.34 $0.10 $0.06 $0.81 $0.07 $0.04 $0.05 $0.03 $0.09 $0.08 $0.27 $0.16 $0.09 $0.16 $0.02 $0.04 $0.02 $0.28 $0.24 $0.01
2018 MARKET SHARE TRENDS**
Antihemophilic Factor Figure 72: Commercial
Figure 73: Medicare
BeneFix Factor VIII (recombinant) NovoSeven Xyntha
Humate-P
Koate
Figure 74: Medicaid
BeneFix Factor VIII (recombinant) NovoSeven Xyntha
Humate-P
Koate
Alphanate Humate-P
Market Share
Market Share
Market Share
2017
2017
2017
12%
57%
5%
20% 3%
63% 3%
2018
28%
45%
14%
Annual Cost per Patient 2017
2018
$465,970 $251,008 $40,083 $347,198 $884,828 $313,030
$217,675 $170,749 $48,545 $166,181 $101,309 $199,619
Allowed Amount PMPM
4% 2018
28%
9%
Brand BeneFix Factor VIII (recombinant) Humate-P Koate NovoSeven Xyntha
17%
30%
$0.12
$0.10
$0.02
$89,062 $408,630 $2,934 $511,355 $22,972 $652,981
$6,800 $23,656 $11,329 $532,739 $69,568 $959,837
$0.05
38%
Brand Alphanate BeneFix Factor VIII (recombinant) Humate-P NovoSeven
Allowed Amount PMPM
$0.05 $0.01
10%
2017
2018
-$75,079 $35,785 $11,581 $2,300
$367,799 $12,970 $24,690 $2,543 $29,937
$0.03 $0.01 $0.01
$0.01 $0.01
$0.07
2018 Total: $0.48
14%
Annual Cost per Patient 2018
$0.68
$0.48
2017 Total: $1.15
33% 1%
29%
2017
Allowed Amount PMPM
$0.22
$0.05
13%
43%
3%
$0.07 $0.18
19%
2018
Annual Cost per Patient
Brand BeneFix Factor VIII (recombinant) Humate-P Koate NovoSeven Xyntha
27%
4%
5% 4%4%
6%
BeneFix Factor VIII (recombinant) NovoSeven
$0.78
2017 Total: $1.92
2018 Total: $3.31
$0.11
2017 Total: $0.10
$0.04
2018 Total: $0.73
$0.02 $0.61
$0.22 $0.02
$0.52
$2.45
$0.05
$0.68
$0.02
**Only drugs with $0.01 PMPM or greater were included in market share analysis.
2019 / MAGELLANRX.COM/TRENDREPORT
40
9%
APPENDIX 2018 MARKET SHARE TRENDS**
Asthma/COPD Figure 75: Commercial Cinqair
Nucala
Pulmicort
Figure 76: Medicare Xolair
Cinqair
Nucala
Figure 77: Medicaid
Pulmicort
Xolair
Nucala
Pulmicort
Market Share
Market Share
Market Share
2017
2017
2017
9% 5%
83%
4%
3%
60%
5% 10%
35%
1%
2018
2018
14%
5%
85%
2018
78%
78%
3%
Xolair
18%
9%
7%
84%
1% 3%
Annual Cost per Patient Brand Cinqair Nucala Pulmicort Xolair
Annual Cost per Patient 2017
2018
$22,799 $18,271 $21 $21,772
$35,061 $22,050 $54 $21,384
Allowed Amount PMPM
Annual Cost per Patient
Brand Cinqair Nucala Pulmicort Xolair
2017
2018
$11,645 $15,011 $870 $18,884
$15,421 $14,775 $452 $17,408
Allowed Amount PMPM
$0.28
2018 Total: $0.44
$0.32
**Only drugs with $0.01 PMPM or greater were included in market share analysis.
41
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
2017 Total: $0.56
$0.41
2018 $12,431 $13 $17,838
$0.03
$0.01
$0.10
$0.10
2017 Total: $0.33
2017 $10,075 $4 $20,812
Allowed Amount PMPM
$0.07
$0.04
Nucala Pulmicort Xolair
$0.02
$0.01
$0.02
$0.01
Brand
$0.07
2018 Total: $0.61
$0.09
2017 Total: $0.17
2018 Total: $0.22
$0.16
$0.19
$0.40
2018 MARKET SHARE TRENDS**
BDAIDs: Crohnâ&#x20AC;&#x2122;s Disease Figure 78: Commercial Cimzia
Entyvio
Remicade
Figure 80: Medicaid
Figure 79: Medicare Stelara
Stelara IV
Cimzia
Entyvio
Remicade
Stelara
Stelara IV
Cimzia
Entyvio
Market Share
Market Share
Market Share
2017
2017
2017
22%
76%
21%
79%
Remicade
10%
Stelara
Stelara IV
89%
1%
1% 2018
1% 2018
25%
2018
35%
72%
1%
1% 1%
Annual Cost per Patient Brand Cimzia Entyvio Remicade Stelara Stelara IV
2018
$23,426 $42,633 $45,264 $109,409 --
$25,133 $41,188 $37,388 $87,609 $8,367
$0.12
$0.03 $0.01
$1.55
1%
1% 1%
Brand Cimzia Entyvio Remicade Stelara Stelara IV
82%
1%
1% 1%
Annual Cost per Patient 2017
2018
$2,904 $26,067 $22,112 ---
$4,065 $25,796 $19,823 $94,403 $5,016
Allowed Amount PMPM
Brand Cimzia Entyvio Remicade Stelara Stelara IV
Allowed Amount PMPM $0.01
$0.03
$0.01 $0.39
$0.49
2017 Total: $2.15
15%
Annual Cost per Patient 2017
Allowed Amount PMPM $0.10 $0.01
62%
$0.76
2018 Total: $2.77
$1.85
$0.20
2017 Total: $0.76
$0.56
2017
2018
-$30,416 $32,454 ---
$4,310 $22,453 $25,132 $47,158 $7,161
$0.01 $0.03
$0.10
$0.01 $0.08
$0.50
2018 Total: $4.18 $3.27
2017 Total: $0.67
$0.54
2018 Total: $0.55
$0.42
**Only drugs with $0.01 PMPM or greater were included in market share analysis.
2019 / MAGELLANRX.COM/TRENDREPORT
42
APPENDIX 2018 MARKET SHARE TRENDS**
BDAIDs: Rheumatoid Arthritis Figure 81: Commercial Actemra Rituxan
Figure 82: Medicare
Cimzia Orencia Simponi Aria
Remicade
Actemra Rituxan
Figure 83: Medicaid
Cimzia Orencia Simponi Aria
Remicade
Actemra Rituxan
Cimzia Orencia Simponi Aria
Market Share
Market Share
Market Share
2017
2017
2017
20%5% 6%
28%
28%
8%
10%
14%
6%
31%
31%
8%
24%
35%
8%
Remicade
5% 4%
30%
2% 2018
2018
21%
6%
28%
26%
9%
10%
2018
16%
5%
30%
29%
9%
11%
33%
23%
29%
6% 6%
3%
Annual Cost per Patient
Annual Cost per Patient
Brand Actemra Cimzia Orencia Remicade Rituxan Simponi Aria
2017
2018
$26,982 $21,562 $33,715 $35,130 $36,486 $23,905
$24,702 $22,537 $32,093 $30,919 $36,127 $21,974
Allowed Amount PMPM
Actemra Cimzia Orencia Remicade Rituxan Simponi Aria
$0.11
2018
$12,085 $14,419 $24,342 $19,047 $19,267 $15,080
$12,513 $15,104 $21,579 $15,222 $21,694 $13,913
$0.04
$0.10
$0.12
$0.05
$0.21
2018 Total: $1.11
$0.18 $0.18
$0.03
2018 $23,290 $7,859 $15,682 $23,319 $18,162 $11,892
$0.02 $0.08
$0.43
2017 Total: $2.12
2017 $24,337 $5,105 $25,773 $27,975 $16,024 $13,589
$0.11
$0.17
$0.28
Actemra Cimzia Orencia Remicade Rituxan Simponi Aria
$0.01
$0.10
$0.24 $0.25
Brand
Allowed Amount PMPM
$0.36
2017 Total: $1.02
2017
Allowed Amount PMPM $0.12
$0.09
Annual Cost per Patient
Brand
$0.64
2018 Total: $2.17
2017 Total: $0.33
$0.63
$0.01
$0.05 $0.04
$0.01
2018 Total: $0.28
$0.12 $0.32
$0.32
$0.73
$0.08
$0.64
$0.68 **Only drugs with $0.01 PMPM or greater were included in market share analysis.
43
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
$0.10
$0.06
2018 MARKET SHARE TRENDS**
Immune Globulin (IV) Figure 84: Commercial
Figure 85: Medicare
Carimune Cuvitru Flebogamma Gammagard liquid Gammaplex Gamunex-C/Gammaked Octagam Privigen
Figure 86: Medicaid
Carimune Cuvitru Flebogamma Gammagard liquid Gammaplex Gamunex-C/Gammaked Octagam Privigen
Carimune Flebogamma Gammagard liquid Gammaplex Gamunex-C/Gammaked Octagam
Market Share
Market Share
Market Share
2017
2017
2017
5%
30%
3%
34%
10%
14%
4%
8%
32%
21%
3%
2018
14%
20%
28%
35%
2% 2%
7%
19%
3%
Carimune Cuvitru Flebogamma Gammagard liquid Gammaplex Gamunex-C/Gammaked Octagam Privigen
2017
2018
$66,568 -$56,784 $47,325 $50,501 $66,458 $35,504 $50,935
$50,375 $31,444 $31,028 $42,102 $56,548 $54,809 $30,003 $43,846
Allowed Amount PMPM $0.06
$0.03
$0.08
$0.25
$0.10
2017 Total: $1.20
35%
25%
13%
$0.08 $0.34
Carimune Cuvitru Flebogamma Gammagard liquid Gammaplex Gamunex-C/Gammaked Octagam Privigen
2017
2018
$19,151 -$12,667 $29,663 $14,638 $34,092 $14,640 $38,353
$28,681 $14,256 $16,620 $30,243 $13,666 $30,055 $18,263 $32,233
Allowed Amount PMPM
$0.39
$0.10
$0.16
$0.52
$0.11
$0.96
$0.27
$0.05
Carimune Flebogamma Gammagard liquid Gammaplex Gamunex-C/Gammaked Octagam Privigen
$0.01
2018 Total: $2.93
2018 $9,574 $39,874 $18,341 $47,162 $31,941 $24,226 $38,174
$1.06 3
$0.01
8%
$0.01
$0.08
$0.08
$0.17 $0.03
2017 Total: $0.66
$0.01
2018 Total: $0.45
$0.01
$0.75 $0.24 $0.06
2017 $14,509 $21,050 $21,052 $34,564 $32,771 $24,868 $66,793
$0.01
$0.19
$0.0
$0.54
9%
1%
Brand
$0.11
$0.52
2017 Total: $2.77
52%
Allowed Amount PMPM
$0.03
$0.18 $0.42
3%
Annual Cost per Patient
Brand
$0.08
25% 3% 2%
$0.79
2018 Total: $1.47
1%
18%
1%
$0.03
$0.05 $0.16
4%
Annual Cost per Patient
Brand
10%
2018
3% 1%
Annual Cost per Patient
46%
4% 1%
2%
2018
4%
35%
Privigen
$0.23
$0.09
**Only drugs with $0.01 PMPM or greater were included in market share analysis.
2019 / MAGELLANRX.COM/TRENDREPORT
44
APPENDIX 2018 MARKET SHARE TRENDS**
Immune Globulin (SQ) Figure 87: Commercial Hizentra
Figure 88: Medicare
Hyqvia
Hizentra
Figure 89: Medicaid
Hyqvia
Hizentra
Market Share
Market Share
Market Share
2017
2017
2017
88%
12%
2018
96%
4%
2018
90%
Brand Hizentra Hyqvia
2018
$55,626 $72,132
$44,208 $65,871
Allowed Amount PMPM
$0.04
94%
6%
Annual Cost per Patient 2017
Brand Hizentra Hyqvia
10%
91%
9%
Annual Cost per Patient 2017
2018
$43,612 $50,394
$44,043 $49,920
Allowed Amount PMPM
$0.04
$0.08
90%
2018
10%
Annual Cost per Patient
Hyqvia
Brand Hizentra Hyqvia
2017
2018
$18,658 $21,447
$16,818 $37,376
Allowed Amount PMPM
$0.09
$0.01 $0.03
2017 Total: $0.20
2018 Total: $0.32
2017 Total: $0.29
2018 Total: $0.41
2017 Total: $0.04
2018 Total: $0.07 $0.04
$0.16
$0.24
$0.25
$0.03
$0.32
$0.68 **Only drugs with $0.01 PMPM or greater were included in market share analysis.
45
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
2018 MARKET SHARE TRENDS**
Oncology: Immunotherapy Figure 90: Commercial Imfinzi
Keytruda
Opdivo
Figure 91: Medicare Yervoy
Imfinzi
Keytruda
Figure 92: Medicaid Opdivo
Yervoy
Imfinzi
Keytruda
Market Share
Market Share
Market Share
2017
2017
2017
22%
73%
5%
25%
73%
25% 2%
2018
2018
5%
33%
56%
Yervoy
71%
1%
3%
2018
40%
6%
Opdivo
53%
4%
4%
39%
54%
3%
Annual Cost per Patient
3%
Annual Cost per Patient
Brand Imfinzi Keytruda Opdivo Yervoy
2017
2018
$24,543 $147,943 $130,283 $289,556
$136,947 $159,623 $170,142 $287,220
Allowed Amount PMPM
Brand Imfinzi Keytruda Opdivo Yervoy
Annual Cost per Patient 2017
2018
-$145,071 $111,105 $142,913
$70,746 $112,843 $117,086 $205,061
Allowed Amount PMPM
2017 Total: $1.20
$0.75
$0.48
$0.37
2017 Total: $4.87
2018 Total: $8.03
$3.69
$0.14
2017 Total: $0.75
2018 Total: $0.92
$0.41
$0.33
$2.62 $1.04
$0.04
$0.25
$3.39 $0.56
2018 $70,831 $95,173 $81,722 $161,178
$0.14
$1.77
$0.84
2017 $58,625 $96,258 $95,039 $253,037
$0.01
$0.20
$0.36
2018 Total: $2.33
Imfinzi Keytruda Opdivo Yervoy
Allowed Amount PMPM
$0.08
$0.28
Brand
$0.35
**Only drugs with $0.01 PMPM or greater were included in market share analysis.
2019 / MAGELLANRX.COM/TRENDREPORT
46
APPENDIX 2018 MARKET SHARE TRENDS**
Oncology: Colorectal Figure 93: Commercial Avastin
Cyramza
Erbitux
Figure 94: Medicare Vectibix
Avastin
Cyramza
Figure 95: Medicaid Erbitux
Vectibix
Avastin
Cyramza
Market Share
Market Share
Market Share
2017
2017
2017
73%
15%
74%
11%
11%
1%
13%
13%
78%
14%
9%
12%
Annual Cost per Patient 2017
2018
$43,962 $31,915 $57,963 $54,697
$45,725 $54,678 $61,988 $65,031
Allowed Amount PMPM
78%
5% 5% 12%
Annual Cost per Patient
Brand Avastin Cyramza Erbitux Vectibix
2017
2018
$25,241 $30,296 $34,799 $40,427
$27,691 $35,017 $29,429 $36,628
Allowed Amount PMPM
$0.12
Brand Avastin Cyramza Erbitux Vectibix
2017
2018
$30,654 $55,200 $30,123 $34,501
$28,116 $90,509 $21,443 $29,393
Allowed Amount PMPM
$0.18
$0.26
$0.03
$0.04 $0.01
$0.07
$0.01
2017 Total: $0.47
$0.09
2018 Total: $0.64
$0.41 $0.13
$0.32
2017 Total: $1.14
$0.10 $0.70
$0.05
2018 Total: $1.05
$0.72
$0.03 $0.01
2017 Total: $0.25
$0.03 $0.17
$0.02
$0.05
**Only drugs with $0.01 PMPM or greater were included in market share analysis.
47
9%
1%
Annual Cost per Patient
$0.07
13%
2018
1%
Avastin Cyramza Erbitux Vectibix
75% 3%
2018
Brand
Vectibix
2%
2018
72%
Erbitux
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
2018 Total: $0.21 $0.14
2018 MARKET SHARE TRENDS**
Oncology: Multiple Myeloma Figure 96: Commercial Darzalex
Kyprolis
Figure 97: Medicare
Rituxan
Darzalex
Kyprolis
Figure 98: Medicaid Rituxan
Darzalex
Market Share
Market Share
Market Share
2017
2017
2017
30%
68%
33%
65%
2018
34%
59%
65%
29%
1%
Annual Cost per Patient Darzalex Kyprolis Rituxan
2017
2018
$105,392 $76,024 $40,443
$109,524 $81,027 $35,466
Allowed Amount PMPM
70%
1%
Annual Cost per Patient
Brand
88%
2% 2018
40%
Rituxan
12%
2% 2018
Kyprolis
Annual Cost per Patient
Brand Darzalex Kyprolis Rituxan
2017
2018
$55,875 $41,588 $17,089
$57,481 $58,921 $19,827
Allowed Amount PMPM $0.01
1%
Brand Darzalex Kyprolis Rituxan
2017
2018
$79,179 $67,825 --
$42,881 $61,860 $28,588
Allowed Amount PMPM
$0.06
$0.09
$0.02 $0.03 $0.04
$0.15 $0.13
2017 Total: $0.32
$0.17
2018 Total: $0.44
$0.41
2017 Total: $1.14
$0.67
$0.65
2018 Total: $1.62
2017 Total: $0.12
$0.88
$0.05
2018 Total: $0.15
$0.28 $0.08
$0.07
**Only drugs with $0.01 PMPM or greater were included in market share analysis.
2019 / MAGELLANRX.COM/TRENDREPORT
48
APPENDIX 2018 MARKET SHARE TRENDS**
Oncology: NSCLC Figure 99: Commercial Alimta
Avastin
Figure 100: Medicare
Cyramza
Keytruda
Opdivo
Alimta
Avastin
Figure 101: Medicaid
Cyramza
Keytruda
Opdivo
Alimta
Avastin
Market Share
Market Share
Market Share
2017
2017
2017
29%
11%
11%
46%
28%
6%
3%
13%
38%
52%
2018
7%
5%
27%
30%
29%
6%
33%
30%
32%
7%
2%
Annual Cost per Patient 2017
2018
$37,186 $54,496 $86,117 $62,213 $60,463
$39,181 $65,326 $46,736 $69,743 $79,588
Alimta Avastin Cyramza Keytruda Opdivo
2017
2018
$23,249 $32,095 $19,292 $32,594 $50,295
$24,020 $36,805 $21,869 $49,487 $51,068
$0.20
2018 Total: $0.84
$1.23 $0.07
2017 Total: $2.58
Alimta Avastin Cyramza Keytruda Opdivo
$0.59
$0.11
$1.03
$0.19
2018 Total: $3.43
2018 $28,297 $30,818 $21,319 $45,492 $41,971
$0.09
$0.09
$0.07
2017 Total: $0.39
2018 Total: $0.40
$0.02
$0.02 $0.01
$0.31
$0.02
$0.02 **Only drugs with $0.01 PMPM or greater were included in market share analysis.
49
2017 $31,207 $20,430 -$45,291 $46,115
$0.16
$0.22
$0.07 $0.11
28%
Allowed Amount PMPM
$0.57
$0.20
$0.24
31%
Brand
Allowed Amount PMPM
2017 Total: $0.54
44%
Annual Cost per Patient
Brand
Allowed Amount PMPM
$0.14
13%
2%
Annual Cost per Patient
Alimta Avastin Cyramza Keytruda Opdivo
Opdivo
2018
2%
Brand
Keytruda
1%
2018
34%
Cyramza
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
$0.55
$0.04
$1.52
$0.10 $0.68
$0.19
2018 MARKET SHARE TRENDS**
Oncology Support: Colony-Stimulating Factors Figure 102: Commercial Fulphila
Granix
Neulasta
Figure 103: Medicare Neupogen
Zarxio
Fulphila
Granix
Neulasta
Figure 104: Medicaid Neupogen
Zarxio
Neulasta
Neupogen
Market Share
Market Share
Market Share
2017
2017
2017
8%
64%
17%
11%
2018
11%
55%
22%
12%
2018
5%
67%
13%
15%
Annual Cost per Patient Brand Fulphila Granix Neulasta Neupogen Zarxio
Allowed Amount PMPM $0.03
$0.02
$0.02
2017 Total: $1.57
$1.50
2018
-$4,296 $28,696 $3,836 $4,322
$8,926 $3,616 $29,550 $4,195 $4,405
$0.01 $0.04 $0.01 $0.03
2018 Total: $2.00
$1.91
80%
12%
8%
2018
6%
56%
17%
21%
Annual Cost per Patient 2017
Zarxio
Brand Fulphila Granix Neulasta Neupogen Zarxio
Allowed Amount PMPM $0.12
$0.04
$0.06
2017 Total: $3.01
$2.79
79%
10%
11%
Annual Cost per Patient 2017
2018
-$1,771 $14,650 $2,731 $2,025
$7,868 $1,376 $16,419 $3,223 $2,260
$0.08 $0.03 $0.02 $0.10
2018 Total: $3.17
$2.94
Brand Neulasta Neupogen Zarxio
2017
2018
$21,741 $3,200 $3,230
$20,642 $3,860 $1,467
Allowed Amount PMPM $0.01
$0.01
2017 Total: $0.84
$0.82
$0.01
$0.01
2018 Total: $0.65
$0.63
**Only drugs with $0.01 PMPM or greater were included in market share analysis.
2019 / MAGELLANRX.COM/TRENDREPORT
50
APPENDIX 2018 MARKET SHARE TRENDS**
Ophthalmic Injections Figure 105: Commercial Avastin
Eylea
Figure 106: Medicare
Lucentis
Avastin
Eylea
Figure 107: Medicaid
Lucentis
Avastin
Eylea
Market Share
Market Share
Market Share
2017
2017
2017
33%
43%
24%
2018
42%
34%
24%
2018
34%
40%
Annual Cost per Patient Brand Avastin Eylea Lucentis
34%
23%
Annual Cost per Patient 2017
2018
$1,378 $11,819 $9,523
$1,115 $11,204 $8,776
Allowed Amount PMPM
Avastin Eylea Lucentis
2017
2018
$1,072 $9,862 $10,184
$834 $9,368 $9,735
17%
59%
27%
14%
Brand Avastin Eylea Lucentis
2017
2018
$308 $8,291 $5,815
$282 $5,897 $5,442
Allowed Amount PMPM $0.26
$0.24
$0.02
26%
Annual Cost per Patient
Brand
Allowed Amount PMPM
$0.01
57%
2018
43%
26%
Lucentis
$0.01 $0.13
$0.04
$0.02
$0.16 $3.23
2017 Total: $0.45 $0.31
2018 Total: $0.50
$3.07
2017 Total: $7.20
$3.89
2018 Total: $7.94
$4.45
2017 Total: $0.07 $0.05
$0.32
$0.09
$0.68 **Only drugs with $0.01 PMPM or greater were included in market share analysis.
51
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
2018 Total: $0.14
FIGURE 108: 2018 HOSPITAL ADMINISTRATIVE CODE TRENDS BY LINE OF BUSINESS COMMERCIAL CPT
MEDICARE
MEDICAID
DESCRIPTION
PMPM
UNIT COST
PMPM
UNIT COST
PMPM
UNIT COST
96413
Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
$0.61
$641.83
$1.12
$360.90
$0.11
$226.53
96375
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug
$0.26
$163.48
$0.22
$46.48
$0.07
$24.73
96365
Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
$0.25
$445.33
$0.48
$221.49
$0.07
$85.06
96374
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
$0.21
$331.15
$0.60
$185.05
$0.13
$57.92
96361
Intravenous infusion, hydration; each additional hour
$0.13
$125.76
$0.12
$41.25
$0.09
$24.79
96415
Chemotherapy administration, intravenous infusion technique; each additional hour
$0.09
$209.02
$0.07
$68.00
$0.01
$49.47
96367
Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour
$0.08
$202.63
$0.10
$72.37
$0.02
$47.70
96372
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
$0.08
$132.90
$0.10
$75.45
$0.06
$22.97
96360
Intravenous infusion, hydration; initial, 31 minutes to 1 hour
$0.07
$382.56
$0.13
$200.16
$0.03
$72.59
96417
Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/ drug), up to 1 hour
$0.07
$265.07
$0.04
$71.74
$0.01
$83.01
96366
Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour
$0.05
$132.80
$0.07
$40.83
$0.02
$26.70
96411
Chemotherapy administration; intravenous, push technique, each additional substance/drug
$0.04
$275.10
$0.02
$78.28
$0.00
$77.61
96416
Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump
$0.04
$565.03
$0.04
$282.16
$0.00
$183.68
20610
Under General Introduction or Removal Procedures on the Musculoskeletal System
$0.03
$453.30
$0.08
$170.46
$0.00
$72.96
96409
Chemotherapy administration; intravenous, push technique; single or initial substance/drug
$0.03
$460.22
$0.08
$309.09
$0.02
$191.90
96376
Intravenous push, single or initial substance/drug; each additional sequential intravenous push of the same substance/drug provided in a facility
$0.02
$113.28
$0.01
$50.51
$0.01
$13.91
96401
Chemotherapy administration, subcutaneous or intramuscular; nonhormonal anti-neoplastic
$0.02
$268.26
$0.06
$123.61
$0.00
$90.02
96402
Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic
$0.02
$252.51
$0.03
$151.36
-
-
96450
Chemotherapy administration, into CNS (e.g., intrathecal), requiring and including spinal puncture
$0.02
$943.10
-
-
-
-
96368
Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion
$0.01
$153.07
$0.00
$122.84
-
-
96523
Irrigation of implanted venous access device for drug-delivery systems
$0.01
$155.14
$0.01
$87.89
-
-
67028
Intravitreal injection of a pharmacologic agent (separate procedure)
$0.01
$635.75
$0.06
$248.44
$0.00
$117.83
95165
Supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)
$0.01
$38.18
$0.00
$6.18
$0.00
$9.63
95117
Immunotherapy injections
$0.01
$105.26
$0.00
$48.40
$0.00
$47.31
2019 / MAGELLANRX.COM/TRENDREPORT
52
APPENDIX FIGURE 109: 2018 PHYSICIAN OFFICE ADMINISTRATIVE CODE TRENDS BY LINE OF BUSINESS COMMERCIAL CPT
95165
MEDICARE
MEDICAID
DESCRIPTION
PMPM
UNIT COST
PMPM
UNIT COST
PMPM
UNIT COST
Supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)
$0.34
$14.48
$0.09
$12.34
$0.06
$7.09
20610
Under General Introduction or Removal Procedures on the Musculoskeletal System
$0.29
$112.17
$0.60
$60.68
$0.06
$67.25
96413
Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
$0.23
$212.78
$0.49
$145.02
$0.03
$122.67
96372
Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
$0.23
$28.36
$0.38
$19.88
$0.13
$17.61
90461
Immunization administration each additional component
$0.12
$11.96
-
-
$0.05
$18.62
67028
Intravitreal injection of a pharmacologic agent (separate procedure)
$0.09
$198.16
$0.70
$113.46
$0.03
$213.69
96365
Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
$0.07
$94.21
$0.15
$73.35
$0.01
$53.03
95117
Immunotherapy injections
$0.06
$13.97
$0.02
$10.15
$0.04
$13.05
96401
Chemotherapy administration, subcutaneous or intramuscular; nonhormonal anti-neoplastic
$0.04
$88.33
$0.12
$77.28
$0.00
$43.89
96367
Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour
$0.03
$44.28
$0.09
$31.30
$0.01
$33.33
96415
Chemotherapy administration, intravenous infusion technique; each additional hour
$0.03
$47.08
$0.05
$31.59
$0.00
$27.55
96375
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug
$0.03
$34.72
$0.05
$19.56
$0.01
$17.21
96417
Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/ drug), up to 1 hour
$0.03
$103.45
$0.06
$68.50
$0.00
$60.20
96416
Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump
$0.02
$226.15
$0.03
$154.91
$0.00
$133.86
96411
Chemotherapy administration; intravenous, push technique, each additional substance/drug
$0.01
$93.11
$0.03
$60.41
$0.00
$51.65
96374
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/ drug
$0.01
$78.13
$0.02
$47.29
$0.00
$40.39
96360
Intravenous infusion, hydration; initial, 31 minutes to 1 hour
$0.01
$89.60
$0.02
$49.50
$0.00
$49.80
96366
Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour
$0.01
$33.20
$0.02
$25.29
$0.00
$22.35
95115
Immunotherapy; one injection
$0.01
$12.63
-
-
$0.01
$10.24
96409
Chemotherapy administration; intravenous, push technique, single or initial substance/drug
$0.01
$171.07
$0.02
$114.19
$0.00
$93.20
96361
Intravenous infusion, hydration; each additional hour
$0.01
$23.34
$0.01
$14.97
$0.00
$12.25
96402
Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic
$0.01
$50.87
$0.02
$33.73
-
-
96521
Refilling and maintenance of portable pump
$0.00
$151.43
$0.01
$132.21
-
-
96368
Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion
$0.00
$29.38
$0.01
$21.03
-
-
53
MAGELLAN RX MEDICAL PHARMACY TREND REPORT / 2019
GLOSSARY ACO........................................................................................................................ accountable care organization
IV....................................................................................................................................................................... intravenous
AS ............................................................................................................................................ankylosing spondylitis
IVIG.......................................................................................................................... intravenous immune globulin
ASP...................................................................................................................................................average sales price
LOB..........................................................................................................................................................line of business
AWP.....................................................................................................................................average wholesale price
MS........................................................................................................................................................ multiple sclerosis
BDAIDs......................................................................................... biologic drugs for autoimmune disorders
MTM.................................................................................................................medication therapy management
CAP...................................................................................................................competitive acquisition program
NCCN........................................................................................... National Comprehensive Cancer Network
CAR-T............................................................................................................chimeric antigen receptor therapy
NCQA......................................................................................... National Committee for Quality Assurance
CMS.............................................................................................Centers for Medicare & Medicaid Services
NDC................................................................................................................................................. national drug code
CNS........................................................................................................................................ central nervous system
NME............................................................................................................................................new molecular entity
COPD................................................................................................ chronic obstructive pulmonary disease
NSCLC............................................................................................................................non-small cell lung cancer
CPT.......................................................................................................................current procedural terminology
PA...................................................................................................................................................... prior authorization
CRL.....................................................................................................................................complete response letter
Part D.......................................................................................................Medicare Prescription Drug Program
Crohn's/UC...................................................................................................crohnâ&#x20AC;&#x2122;s disease/ulcerative colitis
PBM................................................................................................................................pharmacy benefit manager
CSF.................................................................................................................................... colony-stimulating factor
PMPM.................................................................................................................................... per member per month
ESA...................................................................................................................erythropoiesis-stimulating agent
PPPY.............................................................................................................................................. per patient per year
FDA............................................................................................................... U.S. Food and Drug Administration
PSCE.....................................................................................................................................post-service claim edits
FFS.............................................................................................................................................................. fee for service
RA.................................................................................................................................................. rheumatoid arthritis
GI...............................................................................................................................................................gastrointestinal
RAC.................................................................................................................rare autoinflammatory conditions
HAE........................................................................................................................................hereditary angioedema
SCIG.................................................................................................................... subcutaneous immune globulin
HCPCS.............................................................................Healthcare Common Procedure Coding System
SLE.........................................................................................................................systemic lupus erythematosus
HEDIS...................................................................... Healthcare Effectiveness Data and Information Set
SOS............................................................................................................................................................. site of service
HI................................................................................................................................................................. home infusion
SQ................................................................................................................................................................ subcutaneous
Hospital OP.................................................................................................................................hospital outpatient
UC...........................................................................................................................................................ulcerative colitis
ICD......................................................................................................International Classification of Diseases
UM.........................................................................................................................................utilization management
ICER............................................................................................ Institute for Clinical and Economic Review
VEGF.............................................................................................................vascular endothelial growth factor
ICU..................................................................................................................................................... intensive care unit
WAC................................................................................................................................wholesale acquisition cost
IG............................................................................................................................................................immune globulin
YOY............................................................................................................................................................. year over year
2019 / MAGELLANRX.COM/TRENDREPORT
54